SSC 2026 — Part 6: Goals of Care, Transitions & Long-Term Outcomes

Surviving Sepsis Campaign 2026 recommendations for goals of care discussions, advanced directives, time-limited trials, palliative care, ICU transition programs, handoff processes, medication reconciliation, discharge planning, patient and family education, post-critical illness follow-up, physical rehabilitation, mental health support, and cognitive recovery in adult sepsis and septic shock.

guidelines•Mar 2026•guidelines

This section covers the goals of care, transitions of care, and long-term outcomes and recovery for adults with sepsis and septic shock. It addresses goals of care discussions, advanced directives, time-limited trials, palliative care integration, in-hospital transitions (ICU to floor), medication reconciliation, hospital discharge planning, patient and family education about sepsis, education of primary care providers, post-hospital follow-up services, physical rehabilitation, mental health support, and cognitive recovery.

1. Goals of Care

Recommendation 100 — Goals of Care Discussions

For adults with sepsis or septic shock, clinicians should discuss goals of care and prognosis with patients and/or families.

Good practice statement

Change from 2021: Carryover.

Recommendation 101 — Timing of Goals of Care Discussions

For adults with sepsis or septic shock, we suggest addressing goals of care early (within 72 hours) over late (72 hours or later).

Conditional recommendation, low certainty evidence

Change from 2021: Carryover.

Rationale: Goals of care discussions are crucial to patient-centered care, especially in serious or life-threatening conditions like sepsis. In a recent cohort study of over 18,000 patients hospitalized with sepsis, GoC discussions did not occur consistently during hospitalization and there was marked variation in practice across hospitals.

Recommendation 102 — Standardized Criteria for GoC Discussions

For adult patients with sepsis or septic shock, there is insufficient evidence to issue a recommendation regarding the use of a specific standardized criterion to identify patients for goals of care discussions.

No recommendation

Change from 2021: Revisited.

Rationale: The panel identified one non-randomized, before-after pilot study with 84 patients, in which informing the treating hospitalist of the patient’s predicted 30-day mortality on hospital day two to promote early GoC discussion resulted in an uncertain impact (GoC discussion in 16.7% of intervention arm vs. 4.8% in usual care arm; RR 3.50; 95% CI, 0.77–15.88, very low certainty).

2. Advanced Directives

Recommendation 103 — Advanced Directives Opportunity

Health systems should implement strategies to ensure that patients being discharged from hospital after sepsis or septic shock have the opportunity to execute advanced directives.

Good practice statement

Change from 2021: New.

Recommendation 104 — Systematic Establishment Before Discharge

For adults with sepsis or septic shock, there is insufficient evidence to issue a recommendation on the systematic establishment of advanced care directives before hospital discharge.

No recommendation

Change from 2021: New.

3. Time-Limited Trials (TLTs)

Recommendation 105 — Time-Limited Trials of Critical Care

For adults with sepsis or septic shock, there is insufficient evidence to issue a recommendation regarding formal time-limited trials (TLTs) of critical care.

No recommendation

Change from 2021: New.

Remark: A TLT is a collaborative plan to use life-sustaining therapy for a defined duration, after which response to therapy informs the decision as to whether to continue or escalate curative intent ICU care or to instead focus care on other goals.

Rationale: “In our practice,” 64% of the panel uses TLTs, and among these, 64% “sometimes” and 27% “always” explicitly discuss the use of TLTs with the patient or surrogate decision maker. TLTs may help align care with treatment preferences and limit intensity of treatment. However, there is evidence of inequity in how ICU clinicians interact with minoritized populations, and if done poorly or imposed without effective shared decision-making, TLTs could worsen care and inequity.

4. Palliative Care

Recommendation 106 — Palliative Care Integration

The principles of palliative care (which may include palliative care consultation based on clinician judgement) should be integrated into the treatment plan, when appropriate, to address patient and family symptoms and suffering.

Good practice statement

Change from 2021: Carryover.

Recommendation 107 — Routine Formal Palliative Care Consultation

For adults with sepsis or septic shock, we suggest against routine formal palliative care consultation for all patients over palliative care consultation based on clinician judgement.

Conditional recommendation, low certainty evidence

Change from 2021: Carryover.

5. Transitions of Care — In-Hospital

Recommendation 108 — Critical Care Transition Program

For adults with sepsis and septic shock admitted to ICU, we suggest using a critical care transition program, compared with usual care, upon transfer to the floor.

Conditional recommendation, very low certainty evidence

Change from 2021: Carryover.

Recommendation 109 — Handoff Process

For adults with sepsis or septic shock, we suggest using a handoff process of critically important information at transitions of care over no such handoff process.

Conditional recommendation, very low certainty evidence

Change from 2021: Carryover.

6. Screening for Economic and Social Support

Recommendation 110 — Economic and Social Support Screening

Hospitals and health systems should screen patients with sepsis or septic shock for economic and social support needs (including housing, nutritional, financial, and spiritual support) and make referrals where available to meet these needs.

Good practice statement

Change from 2021: Carryover.

7. Medication Reconciliation

Recommendation 111 — Comprehensive Medication Reconciliation

For adults with sepsis or septic shock, comprehensive medication reconciliation should be performed at transitions in care, including at ICU and hospital discharge.

Good practice statement

Change from 2021: Revisited.

Recommendation 112 — Pharmacist-Based Medication Reconciliation

For adults with sepsis or septic shock, we suggest comprehensive medication reconciliation using a pharmacist-based approach at transitions in care.

Conditional recommendation, very low certainty evidence

Change from 2021: Revisited.

Rationale: Two before-and-after studies evaluating pharmacist-based interventions found the intervention may reduce prescription of atypical antipsychotics at ICU transfer (RR 0.84; 95% CI, 0.75–0.94, low certainty) and PPIs at hospital discharge (RR 0.16; 95% CI, 0.09–0.30, low certainty) compared with usual care.

8. Hospital Discharge Planning

Recommendation 113 — Shared Decision Making for Discharge Planning

Clinical teams should provide adults with sepsis or septic shock and their families the opportunity to participate in shared decision making in post-ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible.

Good practice statement

Change from 2021: Carryover.

Recommendation 114 — Written and Verbal Discharge Summary

For adult survivors of sepsis or septic shock and their families, clinicians should provide information about the hospital stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal discharge summary.

Good practice statement

Change from 2021: Carryover.

Recommendation 115 — Follow-Up for New Impairments

For adults with sepsis or septic shock who developed new impairments, hospital discharge plans should include follow-up with clinicians able to support and manage new and long-term sequelae.

Good practice statement

Change from 2021: Carryover.

Recommendation 116 — Transition Information for Patients, Families, and PCPs

Healthcare systems should implement strategies to ensure that patients, their families, and their primary care providers are provided with adequate information to navigate the transition out of hospital.

Good practice statement

Change from 2021: New.

Recommendation 117 — Structured Multi-Component Discharge Planning

For adults who survive hospitalization with sepsis or septic shock, there is insufficient evidence to issue a recommendation regarding a specific structured multi-component discharge planning process.

No recommendation

Change from 2021: Revisited.

Rationale: A meta-analysis of 3 RCTs (592 patients) comparing multi-component discharge planning protocols to usual care found uncertain effects on pain (SMD −0.16), post-traumatic stress (SMD −0.16), hospital readmissions (RR 0.14; 95% CI, 0.02–1.14, low certainty), and uncertain impact on anxiety.

9. Patient and Family Education

Recommendation 118 — Written and Verbal Discharge Information

For adult survivors of sepsis or septic shock and their families, clinicians should provide information about the hospital stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal discharge summary.

Good practice statement

Change from 2021: Carryover.

Recommendation 119 — Sepsis Education Before Discharge and at Follow-Up

For adults with sepsis and septic shock and their families, we suggest offering written and verbal sepsis education (diagnosis, treatment, post-ICU/sepsis syndrome) before hospital discharge and in the follow-up setting.

Conditional recommendation, very low certainty evidence

Change from 2021: Carryover.

10. Education of Primary Care Providers

Recommendation 120 — PCP Competency for Sepsis Survivors

Health systems should implement strategies to ensure clinicians have the knowledge and competency to support sepsis survivors and their families during the post-hospital recovery.

Good practice statement

Change from 2021: New.

Recommendation 121 — Sepsis-Focused Educational Material for PCPs

There is insufficient evidence to issue a recommendation regarding providing sepsis-focused educational material to primary care providers as compared to usual care.

No recommendation

Change from 2021: New.

11. Post-Hospital Support Systems

Recommendation 122 — Support for Sepsis Survivors and Families

Health systems should implement strategies to support sepsis survivors and their families during the post-hospital recovery.

Good practice statement

Change from 2021: New.

Recommendation 123 — Early Post-Hospital Discharge Follow-Up

There is insufficient evidence to make a recommendation on early post-hospital discharge follow-up versus routine post-hospital discharge follow-up.

No recommendation

Change from 2021: New.

12. Long-Term Outcomes and Recovery

Recommendation 124 — Assessment and Follow-Up After Discharge

Health systems should facilitate assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge for sepsis or septic shock.

Good practice statement

Change from 2021: Carryover.

Recommendation 125 — Post-Critical Illness Follow-Up Services

For adult survivors of hospitalization for sepsis or septic shock, we suggest offering post critical illness follow-up services.

Conditional recommendation, low certainty evidence

Change from 2021: Carryover.

Remark: Follow-up services may vary in format, intensity, and duration, depending on locally available resources and patient needs.

Recommendation 126 — Physical Rehabilitation Services

For adult survivors of hospitalization for sepsis or septic shock who received invasive mechanical ventilation for > 48 hours, we suggest offering physical rehabilitation services after hospital discharge.

Conditional recommendation, low certainty evidence

Change from 2021: Carryover.

Remark: Physical rehabilitation services may vary in format, intensity, and duration, depending on locally available resources and patient needs.

Recommendation 127 — Mental Health Support Services

For adult survivors of hospitalization for sepsis or septic shock, we suggest offering services that support mental health after hospital discharge.

Conditional recommendation, low certainty evidence

Change from 2021: Carryover.

Remark: Mental health support services may vary in format, intensity, and duration, depending on locally available resources and patient needs.

Recommendation 128 — Referral for Clinical Symptoms of Mental Health Disorders

Adult survivors of hospitalization for sepsis or septic shock who demonstrate clinical symptoms of mental health disorders should be referred to appropriate healthcare professionals for evaluation and management.

Good practice statement

Change from 2021: Carryover.

Recommendation 129 — Cognition-Targeted Therapies

For adult survivors of hospitalization for sepsis or septic shock, there is insufficient evidence to issue a recommendation regarding cognition-targeted therapies versus usual care.

No recommendation

Change from 2021: Carryover.

Remark: Where cognitive-targeted therapies are being used, it is reasonable to continue using them as they are likely acceptable and feasible.

Post-Sepsis Syndrome — Key Points for Clinical Practice

Up to one-third of sepsis survivors experience significant new impairments. Clinicians should be aware of the following common post-sepsis sequelae:

DomainCommon Sequelae
PhysicalPersistent fatigue, muscle weakness, reduced exercise tolerance, chronic pain, weight loss, hair loss, recurrent infections
CognitiveMemory impairment, attention deficits, executive dysfunction, difficulty with problem-solving, reduced processing speed
PsychologicalDepression, anxiety, post-traumatic stress disorder, sleep disturbances, emotional lability
FunctionalReduced activities of daily living, loss of independence, difficulty returning to work, need for rehabilitation services
Healthcare utilizationIncreased hospital readmissions, frequent ED visits, increased outpatient visits, higher medication burden

Quick Reference: Goals of Care, Transitions & Long-Term Outcomes Summary

GOALS OF CARE, TRANSITIONS & LONG-TERM OUTCOMES — AT A GLANCE

A. GOALS OF CARE
   GPS Discuss goals of care and prognosis with patients/families     [GPS]
   ✓  Address goals of care early (within 72 hours)                   [Conditional]
   —  Standardized criteria for GoC discussions: insufficient evidence [No rec]
   GPS Ensure opportunity to execute advanced directives              [GPS]
   —  Systematic advanced directives before discharge: insufficient   [No rec]
   —  Formal time-limited trials: insufficient evidence               [No rec]
   GPS Integrate palliative care principles into treatment plan       [GPS]
   ✗  Against routine formal palliative care consultation for all     [Conditional against]

B. TRANSITIONS OF CARE
   ✓  Critical care transition program upon ICU-to-floor transfer     [Conditional]
   ✓  Handoff process at transitions of care                          [Conditional]
   GPS Screen for economic and social support needs                   [GPS]
   GPS Comprehensive medication reconciliation at transitions         [GPS]
   ✓  Pharmacist-based medication reconciliation                      [Conditional]

C. HOSPITAL DISCHARGE
   GPS Shared decision-making for discharge planning                  [GPS]
   GPS Provide written/verbal discharge summary with sepsis info      [GPS]
   GPS Follow-up plans for new impairments                            [GPS]
   GPS Ensure transition information for patients/families/PCPs       [GPS]
   —  Structured multi-component discharge planning: insufficient     [No rec]

D. EDUCATION
   GPS Provide sepsis information in discharge summary                [GPS]
   ✓  Written and verbal sepsis education before discharge            [Conditional]
   GPS Ensure PCP competency for sepsis survivor support              [GPS]
   —  Sepsis-focused educational material for PCPs: insufficient      [No rec]
   GPS Implement strategies to support sepsis survivors               [GPS]
   —  Early vs routine post-discharge follow-up: insufficient         [No rec]

E. LONG-TERM OUTCOMES & RECOVERY
   GPS Facilitate assessment for physical/cognitive/emotional problems [GPS]
   ✓  Post-critical illness follow-up services                        [Conditional]
   ✓  Physical rehabilitation after MV > 48 hours                     [Conditional]
   ✓  Mental health support services                                  [Conditional]
   GPS Refer patients with mental health symptoms for evaluation      [GPS]
   —  Cognition-targeted therapies: insufficient evidence             [No rec]

KEY: ✓ = Conditional for | ✗ = Conditional against
     GPS = Good practice statement | — = No recommendation

References