Inclusion Criteria:

• 1. ≥50 years of age AND ≥1 Serious illness\* OR ED clinician would not be surprised if patient died in the next 12 months (a validated prognostic sign)
• 2. English-speaking
• 3. Capacity to consent
• 1. Patient with mild cognitive impairment or mild dementia with capacity to consent (requires a caregiver/study partner to enroll)
• 2. Caregiver of patient with moderate/severe dementia with capacity to consent
• (\*) NYHA Stage III/IV congestive heart failure, chronic obstructive lung disease on home oxygen, chronic kidney disease on dialysis, or metastatic solid tumor cancer. In addition, patients with NYHA Stage I/II congestive heart failure, chronic obstructive lung disease not on home oxygen, chronic kidney disease not on dialysis will be included if recent hospitalization in the last 12 months exists.

Exclusion Criteria:

• 1. Acute physical or emotional distress
• 2. Determined by treating or study clinician not to be appropriate
• 3. Clearly documented goals for medical care\*\* (Unless the treating or study clinician recommends that the intervention is clinically indicated)
• 4. Delirium (assessed using 3D-CAM)
• 5. Already enrolled in this study
• 6. Unable/unwilling to schedule the follow-ups on the calendar
• 7. Receive both the outpatient care for serious illness and primary care outside of the Mass General Brigham health system
• (\*\*)e.g., MOLST, medical order for life-sustaining treatment, documented serious illness conversations in clinician notes within the last 3 months, etc.