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Palliative care is grounded in attentiveness, responsiveness and alignment of treatment with patients’ values and preferences. Shared decision-making, advance care planning and goal-concordant care have become central markers of ethical and high-quality practice, reducing unwanted interventions and supporting patient autonomy. 1–3 Yet alignment alone does not guarantee comfort. This tension is increasingly visible in contemporary palliative care, where structured communication requirements, documentation standards and repeated goal reviews have intensified the procedural demands placed on patients nearing the end of life.