Treatment decisions should be based on patients’ goals of care to provide an ethical, patient-centered framework for decision making. The purpose of this study is to improve our understanding about how patients’ and surrogates’ goals of care are communicated and interpreted in an medical intensive care unit (MICU). One hundred patients admitted to an MICU, or their surrogates, responded to an open-ended question about goals of care for their hospitalization followed by a closed-ended question regarding their most important goal of care. Investigators interpreted participants’ open-ended responses and compared these interpretations with participants’ closed-ended, most important goal selections. Investigators’ interpretations of participants’ open-ended goals of care responses matched participants’ closed-ended most important goal of care in only 28 of 100 cases. However, there was good interrater reliability between investigators in their interpretation of participants’ open-ended responses, with agreement in 78 of 100 cases. Clinicians should be cautious in interpreting patients’ or surrogates’ responses to open-ended questions about goals of care. A shared understanding of goals of care may be facilitated by alternating open-ended and closed-ended questions to clarify patients’ or surrogates’ responses.