Advance Care Planning
The form is not the conversation.
ACP Is More Than a Code Status
Advance care planning (ACP) is the process of understanding a patient's values, goals, and preferences in the context of their illness trajectory — and translating that understanding into clinically meaningful documentation. Code status is one output. It is not the whole conversation.
The goal is not to obtain a form. The goal is to understand what matters before a high-stakes decision has to be made.
What the Conversation Actually Covers
Prognostic awareness — does the patient understand their illness trajectory? Values clarification — what matters most, what are they willing to go through, what outcomes would be unacceptable? Goals of care — living as long as possible, maintaining function, avoiding hospitalization, being comfortable.
Identifying unacceptable health states is as clinically important as identifying desired interventions.
When to Have It
ACP is a process, not a single conversation. High-yield triggers: hospitalization for serious illness, new serious diagnosis, significant functional decline, recurrent hospitalizations, expressed change in patient priorities.
Documentation and communication across care settings are as important as the conversation itself. A plan that does not travel with the patient cannot guide care.
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