Question special

The geriatric patients, once cared for by geriatricians, are now being seen in primary care at an increasing rate. Many of them are very old with chronic illness, dementia, frailty, and failing social support system (frequently cared for at home by someone who is just as old and just as sick). Not only it is time consuming to care for them due to the complexity of their illness(s), the Evidence Based Medicine (EBM) are mostly lacking for those patients. What are your thoughts/ ideas on how to manage, in PC setting, listening, goal setting and honoring preferences of care for the patient and family?