The PRAXIS Nexus The PRAXIS Nexus

Setting (and Achieving) Goals Together with Our Patients

Posted on September 12, 2022   |   

This article was written by Michael W. Hess, MPH, RRT, RPFT

As clinicians, we are often called upon to make recommendations. We have access to peer-reviewed research, so we typically have an idea of the most appropriate therapy for a given situation. Wheezing? That calls for some bronchodilators. Hypercapnea? We may consider noninvasive ventilation. We tend to be confident that we know the best thing to do in most cases.

Despite our best efforts, sometimes there is a mismatch between what is in the textbook and what our patient truly needs. In our enthusiasm to provide optimal care, it can be easy to miss that those two things are not always the same. Unfortunately, when we lose sight of that, we can take our patients down a path where expectations do not match reality. That, in turn, leads to frustration and a lack of trust, which can have a devastating effect on therapy adherence and outcomes. That is why collaboration and the process of shared decision-making in goal setting and planning is essential to care.

A Little More Conversation

So, what is shared decision-making? It's clear, open communication between the clinician and the patient that facilitates the development of a therapy plan that balances the patient's needs and values against potential risks and outcomes.1 Historically, many (if not most) clinical decisions were left to the people carrying the stethoscopes, and patients would dutifully carry out their instructions (or not). Studies have indicated that this model often led to decisions being made not by evidence but by the preferences of the ordering clinician, leading to massive inconsistencies in care.2 This, combined with the patient perceiving that he or she has no say in a treatment plan, can have a significant negative impact on the likelihood of adherence to that plan. However, when medical decisions are made collaboratively, people are often more likely to accept and stick with their prescriptions and therapies.3

Shared decision-making can also facilitate behavior change. According to the Transtheoretical Model, the process of change takes place in stages ranging from pre-contemplation to maintenance of the change.4 It should be obvious that the more people understand the potential risks and benefits of a change, the more likely they are to stick with it. Each person looking to make a change must have some level of “buy-in” to see results. The tricky part is figuring out how to achieve that. Take tobacco treatment for example. Most people who smoke know it is bad for them, and most have repeatedly been advised to quit, because that is what is best. Yet many continue to smoke. So, how can YOU be successful when everything else has failed? You must first find out what motivates that individual patient. Do they want to get healthier? Do they want to spend less money or be a better example for their kids or grandkids? A real one-on-one conversation, rather than just listing off instructions, enables you to start building a connection.

Building on that connection, you can begin to see what realistic goals are. For a personwho smokes a full pack of cigarettes a day, quitting altogether may seem like a daunting challenge. That person likely tried quitting previously and then felt guilty about not being successful. But, perhaps it's possible to cut it down to half a pack. Once that goal is met, you can work with your patient to make further progress. Each person's finish line is in the same place - whether it takes 50 steps or 500; the important part is helping them reach it.

Getting S.M.A.R.T. with Goals

Once you have established common ground with your patient, you can start setting realistic goals. Health care providers can take a page from the business world here because S.M.A.R.T. goals allow for the observation of concrete progress. If you are not familiar with S.M.A.R.T. goals, they are:

  • SPECIFIC: "I want to quit smoking," or "I want to exercise longer."
  • MEASURABLE: The number of cigarettes smoked, or steps taken in a day.
  • ATTAINABLE: Is the person willing and able to achieve a goal based on your shared conversations?
  • RELEVANT: Is the goal something that resonates with the person's motivations based on your shared conversations?
  • TIME-BASED: "I want to quit smoking by the end of the year."

You will note that shared decision-making is a key component to several of these goals. Those conversations are essential to creating reasonable S.M.A.R.T. goals and empowering your patient to take control of his or her condition.

Bringing it Together

Paradoxically, the best answer is not always the right answer. By collaborating with your patients, you give them the ability to deal with the pros and cons of procedures or other therapies. You enable them to make informed decisions based on their values and their priorities, and you increase their odds of sustained success. In the end, isn't that what is best for all?


  1. US Department of Health and Human Services National Learning Consortium. Shared Decision Making Fact Sheet - December 2013. Published online 2013. Accessed September 2, 2022 at
  2. Strategy 6I: Shared Decisionmaking | Agency for Healthcare Research and Quality. Accessed September 1, 2022.
  3. Joosten EAG, DeFuentes-Merillas L, de Weert GH, Sensky T, van der Staak CPF, de Jong CAJ. Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status. Psychother Psychosom. 2008;77(4):219-226. doi:10.1159/000126073
  4. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. American Journal of Health Promotion. 1997;12(1):38-48. doi:10.4278/0890-1171-12.1.38


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  • Good info and advice. Thanks Mike and Kristen
  • Well Done Mike. I couldn't agree more. After 2 weeks in the hospital, 9 days in an acute care facility with 90 minutes a day of PT and 9 days in a nursing home with 40 minutes of PT. The powers that be wanted me to have "home health" and "physical therapy" come in to my house. I sat and I wondered to myself where is a respiratory therapist . My issue was pneumonia created by fungal infections. The 9 days in the nursing home for primarily waiting to finish up a picc line drug. I refused both the home health and physical therapy. Maybe I wa wrong, but I was quite frankly tired of having people around me who really didn't understand what I was dealing with. I repeat, well said Mike.
    Rickie Daniels
  • I skipped the acute care and nursing home and came straight home with Home Health. I made the right decision for me. I have a wonderful friend and neighbor who vowed to either take care of me at my home or in her home.

  • In 2018 my pulmonologist put me on nebulized medication, nebulized steroids and suggested Oxygen. I went home and read everything I could and decided to do without the steroids and oxygen. I have not had an exacerbation since.
    I know doctors have good intentions but like we saw when Covid began, doctors followed a protocol and many people suffered and died until some very brave emergency/icu doctors started thinking out of the box with their brains, and had to put their careers on the line to save lives. They also found out new things about lungs, platelets etc that Im sure could shed some new light on Lung issues out for yourselves, good luck everyone.

  • I also wanted to say that those doctors who REALIZED how better to treat Covid spread the word through Twitter, so thank goodness for technology.
    I myself was watching the death numbers in different Florida counties and REALIZED some counties had way more deaths per population, I actually called the hospital emergency rooms and told them I was no one but I knew the Ventilators and/or the Ventilator settings were killing people. They thought I was nuts but I told them to google it! and hopefully some told the doctors about the crazy lady who called.
    My point is COPD doctors might benefit from getting together and exchanging information and new ideas.
    I'll shut up now,

  • I like this approach multiple clinicians working at achieving success working with patients. As a smoking cession facilitator I have found it may take individuals several attempts at quitting before actually quiting. The ability to give consistent opportunities to clients is also a factor.

  • MM4
    As someone who's case never fit in with their known textbook, it's always been a collaborative effort between the doctors and my parents, and then myself as i got older. Unfortunately, I've had a couple doctors that tried treating just what they saw on paper and refused to listen to my input, and let's just say it didn't work. Lol I went back to my other doctor even though it's a bit of a drive.