I have the same problem at times. Sometimes a quilt will be easy. For example, a couple of years ago I did a quilt for a friend's daughter who was graduating from High School. She is a very good artist already, and the backing on her quilt was a novelty print of Van Gogh's "Starry Night". Well, for me, that screamed a swirly motif, edge to edge on the quilt.
Other times I stare at the quilt and either come up with something I don't have time for, or something I feel is uninspired.
Here's something to remember thought: No matter what you decided, the recipient is always happy for what you do and in love with their special gift.