Patients  Inclusion Criteria:  Age greater than or equal to 18 years old Carry an active invasive cancer diagnosis (other than non-melanoma skin cancer) Self-report as a member of a federally recognized tribe Reside on Pine Ridge, Rosebud, or Cheyenne River Indian Reservations or within the Contract Health Service Delivery Area of the Pine Ridge, Cheyenne River, or Rosebud IHS Service Unit Able to complete baseline surveys Able to provide informed consent Have an identified caregiver A clinician responds "no" to the question: "Would it be a surprise if this person died in the next 12 months?"  Exclusion Criteria:  Do not meet any of the above criteria  Caregivers  Inclusion Criteria:  Are greater than or equal to 18 years old Reside in Pine Ridge, Rosebud, or Cheyenne River Indian Reservations or within the Contract Health Service Delivery Area of the Pine Ridge, Cheyenne River, or Rosebud IHS Service Unit Identified as caregiver by an enrolled patient; Caregiver will be defined as anyone who patients identify as a consistent source of physical, mental, emotional or spiritual support. Able to complete baseline survey Able to provide informed consent  Exclusion Criteria:  Do not meet any of the criteria above