Advance Care Planning (ACP) is a process for patients and their families to discuss:
- their wishes and goals related to treatment and end-of-life care,
- clarify related values and goals,
- and state preferences through written documents and medical orders.
The ACP process can begin at any time and can be revisited periodically, but becomes more focused as health status changes. In situations where a patient’s decision-making capacity is limited, healthcare providers turn to loved ones to make decisions.
When there have been no ACP conversations between the patient and loved ones, loved ones are left to make decisions regarding life-sustaining treatment without input from the patient or with little knowledge of the patient’s wishes.
ACP Resources
There are many online resources available to assist with ACP. Below are links to several resources that can help nurses plan.
Primary Resources
- Advance Care Planning Decisions – offers videos and resources
- American Association of Retired Persons (AARP) – offers basic resources on caregiving
- American Bar Association – offers a toolkit for healthcare advance planning
- The American Cancer Society – offers information about advance directives
- Begin the Conversation – created by the Lower Cape Fear Hospice in Wilmington, NC
- Caring Info – a program of the National Hospice and Palliative Care Organization (NHPCO)
- The Centers for Disease Control – includes a list of selected resources for ACP
- The Conversation Project – an initiative of the Institute for Healthcare Improvement (IHI)
- Courageous Parents Network – pediatric advance care planning
- Defining Hope – a documentary feature about people weighing what matters most at a critical time
- Five Wishes – an easy-to-use legal advance directive document available in a variety of languages
- My Directives – offers both online and mobile app options for advance directives
- National Healthcare Decision Day (April 16) – national initiative encouraging the expression of wishes
- National Physician Orders for Life Sustaining Treatment (POLST) Paradigm – provides materials for planning
- PREPARE For Your Care – a step-by-step program with video stories to help you prepare
- Respecting Choices – an internationally recognized, evidence-based program that addresses the ACP process
Additional Resources
- The Institute of Healthcare Improvement (IHI) – offers several videos such as Practice Makes Perfect and Who Will Speak for You, a letter to her daughters from an IHI colleague, and a white paper titled Conversation Ready: A Framework for Improving End-of-Life Care
- The National Hospice and Palliative Care Organization (NHPCO) – video on The Gift of Advance Care Planning and a free state-specific advance directive forms guide available online.
- The American Academy of Nursing (AAN) – released a policy brief on advance care planning in diverse, underserved populations
- HPNA – position statement on Advance Care Planning