Background: Addressing goals of care involves an added layer of complexity in never-competent patients. The concept of best interests is used to guide decision-making for these patients; however, this can be difficult for many reasons. To help providers recognise and minimise these challenges, we recommend steps that can be taken to support decision-makers and identify a patient's best interests. Method: We describe a 61-year-old man with complex past medical and psychiatric history who lacked capacity to make complex medical decisions his entire life and outline the struggles faced when trying to make decisions regarding his care. Results: Data are lacking regarding the best approaches to shared medical decision-making in never-competent patients. It is reasonable to approach such decisions using currently available communication tools. Conclusion: More studies need to be conducted to determine the best approaches to shared medical decision-making in never-competent patients.