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What is Advance Care Planning?

Hello Transformation Tribe! Today we are going to address a really important topic that most folks have never heard of- Advance Care Planning.

So what is Advance Care Planning and why is it important?

Advance Care Planning means self-reflecting and communicating with your family and friends about your wishes for treatment in the event of a serious illness or at the end of life.

It is also very important that you have these conversations with your doctor and that he or she documents this information in your medical record. That way, everyone who cares for you and anyone who may have to provide your medical care when that serious event occurs, will know exactly what your medical wishes are.

Unfortunately our current healthcare system is centered around prolonging life at all costs. Here is a humorous article faking a remake of the Disney classic The Lion King, which unfortunately is a very accurate portrayal of the current U.S. healthcare system:

Advance Care Planning can often be a difficult thing to think about, but at a time when so much seems out of your control this will allow you to take ownership by having these conversations and making decisions with your family and doctors.

Only about 1/3 of patients with chronic illnesses have advance care planning documentation completed.

When it comes to terminal illness, end of life conversations, or planning for unforeseen events, it is best that everyone starts the conversation well in advance and then continues the dialogue over time. You must then document this information in writing, because when the time comes you may not be able to speak for yourself or may be in a state where caretakers are concerned that they might accidentally misinterpret your thoughts and feelings.

It is also incredibly important to learn about hospice in a timely fashion to support you and your loved ones throughout the final months of life. I’m a huge fan of hospice providers because they are so caring and giving and supportive to patients and their families during a very difficult time. Check out this video to see what I mean.  

Here is an incredibly insightful book and PBS special by Dr. Atul Gawande on Advance Care Planning. I highly recommend watching the special as well as reading the book if you have time. BEWARE: you may cry!!

And in case you aren’t familiar, Dr. Gawande is the CEO of Haven, the new company created by J.P. Morgan, Amazon, and Berkshire Hathaway to reduce healthcare costs and improve health outcomes. More importantly, he is one of my healthcare heroes. 🙂

So what are the Advance Care Planning documents you should know?

Goals of Care Documentation: This is a conversation between you and your medical providers that documents your goals and wishes for care in the electronic medical record to relay this information across the health system.

Non- Temporary Advance Directive (Power of Attorney): This document states who will make medical decisions for you in the event you cannot speak.

Note that there is also a document called a Temporary Advance Directive that you complete for specific medical events such as surgeries, but that document is only in the event that something goes wrong for that surgery and does not endure past that event.

Physician Order for Life Sustaining Treatment (POLST): This document indicates whether you want fully aggressive treatment if you cannot breathe or if your heart stops.

Note that POLSTs really should only be completed if you do NOT want fully aggressive treatment that attempts to bring you or your loved one back to life. In oversimplified terms this means that if you die you would like to remain dead and therefore you should complete a POLST. Many individuals choose this route due to the importance of their quality of life but you should proactively have these conversations with your doctor about what life for you would look like and whether you are ok with that.

Like I mentioned earlier, be sure you have your own copies of these documents but both your legal and medical team should I have these documents as well. Your medical provider should have the documents uploaded into the Electronic Medical Record (EMR) and these need to be communicated across all providers you see since they may not be on the same EMR.

Here is an example that shows the importance of a POLST:

An elderly woman well into her 80’s completed a POLST because she knew that when her heart stopped or she stopped breathing she wanted to go naturally and peacefully. Unfortunately after a hospitalization she was placed in a nursing home that did not have her POLST documentation. When her heart stopped and they found no POLST they attempted to bring her back to life with CPR. Unfortunately the CPR broke her frail ribs but it did not bring her back to life. The family and primary medical team were upset but there was nothing they could do. They simply hoped she didn’t feel the pain of her ribs breaking in her final moments.


Need additional resources to support you and your loved ones in having and documenting these conversations with your family and doctors?

My Health Care Transformation Handbook has an entire chapter on Advance Care Planning, including the types of questions to guide Goals of Care conversations, the Advance Care Planning Checklist, and more! You can also check out the information in our For the Adults or For the Wise Elders Academy courses.

Any questions, comments, concerns be sure to CONTACT US. I hope you take the opportunity to learn from these tools and engage in advance care planning to advocate for yourself and your loved ones.


What is your current organizational strategy to enhance and improve your Advance Care Planning efforts across the organization? Are you aware of your current EMR documentation rates of Goals of Care and Advance Directives, especially in your advanced illness specialties such as oncology and cardiology in addition to primary care? Are you implementing cost-effective clinic operations improvements including provider and staff training, EMR flags and templates for documentation and billing, and data transparency on clinician performance?

CONTACT US to learn how we can support you to be a leader in advance care planning as a tool to achieve your value-based care goals now and in the future.

Cheers to your Health and Happiness!