Background Rehabilitation and goal setting can support one of the key principles of palliative care, to help people live actively until they die. Until recently, no theory based practice framework has existed. A framework for goal setting in palliative care (G-AP-PC) was therefore developed and implemented systematically, through 4 phases, in one hospice.

Aims To develop and implement a theory based goal setting framework to guide and support patient-centred goal setting in practice.

Methods Phase 1: Gathering information about goal setting practice through a structured literature review and observation of practice in one hospice.

Phase 2: Identifying and applying theories which could underpin a goal setting framework and support patient-centred goal setting.

Phase 3: Use of a participatory approach, based on Normalisation Process Theory (NPT) to develop and implement a framework for goal setting.

Phase 4: Evaluation of the impact of implementing GAP-PC, using interviews (patients/professionals), a questionnaire (professionals) and case note analysis.

Results G-AP PC was successfully implemented. It helped professionals to work as a team; shift their attention from a solely symptoms/problems/risk based approach to focusing on patients’ goals; act on what patients wanted to achieve, within short timescales, with documentaryevidence of practice.

Patients reported that use of G-AP PC allowed them to focus on goals that were important to them. There was also evidence that goal setting helped increase their motivation and self-efficacy.

Conclusions and application to hospice practice Use of an explicit, theory based goal setting framework provides a mechanism for ensuring that individual, patient centred goals are established, documented and reviewed. It also helps professionals focus on what is important to patients. Following successful implementation in one ward, G-AP PC is now being used throughout the hospice to support people to live until they die. Future research will explore the potential application of this framework to other palliative care settings.