Track 18: Advance Care Planning (ACP)

Advance Care Planning (ACP)

Advance care planning (ACP) is a procedure that aids persons of any age or health status in understanding and communicating their own personal values, life objectives, and healthcare preferences. ACP seeks to support people in receiving medical treatment that is in line with their values, objectives, and preferences. Whether a person is well, has a mild to moderate chronic illness, or has an advanced life-threatening illness and is anticipated to pass away within the next 12 months, the timing and form of ACP may differ. No matter the clinical situation, ACP ought to be proactive, timely, and integrated into standard care. ACP should also be reviewed whenever a person’s health status changes.

ACP calls for dialogue between patients, their family or other decision-makers, and their health care professionals. It works best when taking into account the patient’s relationships and culture, which will then influence specific medical treatment decisions that can be documented in an advance directive (AD). Although it is rarely the main goal of ACP discussions, ACP may include the completion of an AD. ACP’s mission is to make sure that patients get care that is in line with their values and goals.

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In the event that a patient is rendered unable to make decisions regarding their own treatment, voluntary ACP is a face-to-face service between a Medicare physician (or other certified health care provider) and the patient to discuss the patient’s healthcare preferences.

You can discuss advance directives (ADs) with or without completing legal forms as part of this conversation. Based on the person’s values and preferences, an AD selects an agent and/or documents the person’s requests on their medical treatment. Usually, you may discover ADs on the website of your state’s attorney general. For instance, living wills and instruction directives are examples of ADs.

The Function of Multidisciplinary Teams in the Treatment of Chronic Kidney Disease Clinic

ACP for CKD patients aids in identifying life objectives and can serve as a valuable framework for talks between patients, their families, and healthcare professionals. ACP should be a dynamic approach that can adjust to the altering healthcare requirements of the CKD patient and enable intervention as needed. Early ACP beginning allows patients to carefully and deliberately explore their alternatives for kidney replacement therapy, their possible impact on daily life, and the choices and preferences that most accurately reflect their values and life objectives. An advance care directive is often the result of such conversations.

What Particular Precautions Are Necessary for People with Parkinson’s disease, Multiple Sclerosis, or Amyotrophic Lateral Sclerosis?

Advance care preparation is a continuous procedure that should start with the diagnosis and go on throughout the course of the illness (see Table 56-2). It is crucial to evaluate decision-making capacity for advance care planning talks given the significant prevalence of cognitive impairment among patients with neurodegenerative diseases. Any doctor can assess a patient’s decision-making capacity, which is decision-specific. A patient with PD and mild dementia, for instance, might be able to designate a health care proxy but not be able to decide whether to get cardiopulmonary resuscitation in the event of a catastrophic disease.

Advance care planning, hospice care, palliative care, and advance directives

It entails constant dialogue on objectives, values, and beliefs between patients, their families, and medical providers. The patient can learn what matters to them and their family members in terms of present and future medical care by exploring these subjects. The ACP approach educates and enables people to make decisions about their present and future care.

Advanced Decisions

The legal documents used to document treatment preferences are known as advance directives (ADs). Depending on the location, these documents may also include a living will, a durable power of attorney for healthcare (healthcare proxy), physician orders for life-sustaining treatment (POLST), and medical orders for life-sustaining treatment (MOLST).

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Sub-tracks of Advanced healthcare Planning

  • Hemodialysis patients
  • Liberalism
  • Systematic narrative review
  • Quality of End-of-Life Care among Older Adults
  • Advance Care Plans and Future Welfare.
  • The Feasibility of Promoting Conversations
  • Systematic review of evidence
  • Patient and family engagement
  • Primary care
  • Thematic analysis

Advance Care Planning Resources:

  • Advance Care Planning Decisions
  • American Association of Retired Persons (AARP)
  • American Bar Association
  • The American Cancer Society
  • Begin the Conversation
  • Caring Info
  • The Centers for Disease Control
  • The Conversation Project
  • National Physician Orders for Life Sustaining Treatment (POLST ) Paradigm
  • PREPARE For Your Care


  • The ACP process is coordinated and collaborative. In order to help medical practitioners better serve their requirements, it seeks to gain an awareness of the patient’s treatment and care objectives.
  • Advance care planning is crucial for recognizing the end of life and identifying early palliative care needs. Other advantages include less severe medical treatment and a higher standard of living just before death. Additionally, it aids in family conflict resolution, bereavement adjustment, and assisting families in preparing for a loved one’s death.
  • Additionally, because such decisions are essentially private, subject to change over time, and affected by a variety of sociocultural and health literacy factors, advance care planning can oversimplify the decision-making process.
  • When a person is unable to speak for themselves, ACP can help make their wishes known. All individuals can benefit from ACP, but it’s especially helpful for those who have chronic or life-threatening illnesses and are at risk of having their health decline.
  • Consistency in care is guaranteed by care planning. Staff from various shifts, rotes, or visits can use the information from a thorough care plan to provide the same level of support and care. This enables patients to obtain high-quality, safe, effective, and responsive care in a well-led service.

Why it’s Important Everyone benefits from advance care planning, including you, your family, caregivers, and medical professionals.

  • It makes sure you get the treatment you genuinely want.
  • It enhances ongoing and end-of-life care, as well as satisfaction for the individual and the family.
  • Families of those who have engaged in prior care planning experience less stress, depression, and anxiety and are happier with the care they receive.
  • It lessens unneeded transfers to acute care and unnecessary treatment for healthcare personnel and organisations.
  • In the event that you are extremely ill or injured and have not expressed your preferences in writing or designated a replacement decision-maker, medical professionals will decide how to treat you based on what they believe is in your best interests. This might involve receiving treatments you wouldn’t desire.