Advance care planning (ACP) is the process of understanding a patient's values, goals, and preferences in the context of their current and anticipated health trajectory — and translating that understanding into clinically meaningful documentation and communication. Code status is one component, 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.
CLINICAL PRINTABLE
Coming Soon.
A clinical reference for this topic is in development.
1 · What ACP Actually Encompasses
- Prognostic awareness — helping the patient understand their illness trajectory in a way that supports informed decision-making.
- Values clarification — understanding what matters most to the patient, what they are willing to go through, and what outcomes they would find unacceptable.
- Goals of care — translating values into goals (e.g., living as long as possible, maintaining function, avoiding hospitalization, being comfortable).
- Treatment preferences — translating goals into specific decisions about interventions (resuscitation, mechanical ventilation, artificial nutrition, hospitalization).
- Identifying a healthcare decision-maker — ensuring someone is designated and understands the patient's wishes.
- Documentation and communication — ensuring the plan is recorded and accessible across care settings.
2 · Practical Conversation Starters
"What is most important to you if your health gets worse?"
"What abilities are so important to you that you cannot imagine living without them?"
"If you became too sick to speak for yourself, who would you want making medical decisions with your healthcare team?"
"Have you thought about what kind of care you would want if you were very seriously ill?"
"Is there anything you are worried about when you think about the future of your health?"
3 · When to Revisit ACP
- Hospitalization — particularly for a serious or life-limiting illness.
- New serious diagnosis or significant change in prognosis.
- Disease progression or recurrent utilization (repeated hospitalizations or ED visits).
- Significant functional decline or increasing dependence in ADLs.
- Major change in patient priorities or expressed change in preferences.
- Transition to a new care setting or care team.
Bottom Line
ACP is a process, not a single conversation — it should be revisited as diagnosis, prognosis, function, and patient priorities change.
EVIDENCE & REFERENCES
- Sudore RL, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53(5):821-832. doi:10.1016/j.jpainsymman.2016.12.331
- Bernacki RE, Block SD; American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003. doi:10.1001/jamainternmed.2014.5271
- Detering KM, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345. doi:10.1136/bmj.c1345