Advance Care Planning: Office-Based Care

December 13, 2023 | Ambulatory Care Risk Management

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​​​​​​​​​​​​​​​​​​​​​​​​​​Advance care planning (ACP) is a continuous process of communication among patients, their family or other decision-makers, and healthcare providers that documents a patient's personal preferences, values, and goals regarding future medical care. ACP is a routine aspect of palliative and end-of-life care—especially for people who are diagnosed with a serious or terminal illness. However, many individuals lack any formal, legal plans (i.e., advance directives), which can create tension or uncertainty among family members and providers during emotionally charged times, as well as risk a patient's right to self-determination, bodily autonomy, and sense of dignity. Therefore, ACP is encouraged for all adults regardless of age or health status to ensure a person's wishes are honored as their life and health status change, whether over time or unexpectedly. To that end, this toolkit can help ensure that ACP discussions are completed, optimized, and well-documented.

ACP and the completion of advance directives are key elements of person-centered care and shared decision-making (SDM)—two essential components of modern, high-quality healthcare that lay the foundation for a respectful partnership among patients, their decision-makers, and providers.

Person-centered care focuses broadly on what matters most to individual patients as their healthcare needs, goals, and preferences change over time, addressing the "whole person" (e.g., medical, behavioral, spiritual, and emotional health) rather than focusing only on the diagnosis, treatment, and management of a patient's medical condition(s). See Person-C​entered Care...

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