Advance Care Planning Conversations
Last Reviewed: March 30, 2020
What You’ll Learn
- Elicit permission to begin conversations about advance care planning with the patient and their family
- Define the goals of advance care planning conversations for the patient
- Position advance care planning in the future, and distinguish it from present decision-making
- Recognize that advance care planning conversations inform your understanding of the patient’s values and allow you to explore the future with the patient in a non-threatening way
What You’ll Earn
CAPC members can earn the following free continuing education credits:
- Case Management: 1.00 CE
- Licensed Professional Counselors: 1.00 CE
- Medicine: 0.50 CME, 0.50 ABIM MOC (Medical Knowledge Only)
- Nursing: 1.00 CNE
- Social Work: 1.00 CE (NYSED)
- Social Work: 1.00 CE (NASW)
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Tools & Resources
Advance Care Planning Conversations: Key Takeaways
Stepwise approach to discussing advance care planning with patients or surrogates. Center to Advance Palliative Care and VitalTalk, 2015.members login
Billing and Coding for Advance Care Planning (ACP) Services
Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.members login
Billing the Physician Fee Schedule for Advance Care Planning Services
One-page reference guide to billing for advance care planning conversations. Center to Advance Palliative Care and Acevedo Consulting, August 2016.members login
Optimizing Billing Practices
Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.view
Communication Phrases in Palliative Care
Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.members login
Clarifying Goals of Care
Strategies for eliciting patient goals and preferences to inform treatment decisions.start the course
VitalTalk - Quick Guides
One-page guides with actionable tips for conversations with patients with serious illness. Free to download, print and share with others.view
YourCarePlan POLST Training Videos
Brief videos to help clinicians hold appropriate conversations with patients about the completion of the POLST form (Physician Orders for Life Sustaining Treatment).view
Diane E. Meier, MD, FACP, FAAHPM
Director, Center to Advance Palliative Care
Robert Arnold, MD
Distinguished Service Professor of Medicine
Chief, Section of Palliative Care and Medical Ethics
Anthony Back, MD
Co-director, University of Washington Center for Excellence in Palliative Care
Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN. Consultant, Center to Advance Palliative Care.
Andrew E. Esch, MD, MBA. Consultant, Center to Advance Palliative Care.
Lynn Hallarman, MD. Associate Professor of Medicine, Director of Palliative Medicine, Stony Brook University Hospital.
Jaime Goldberg, MSW, LCSW, ACHP-SW. PhD student, University of Wisconsin-Madison School of Social Work.
Philip Higgins, PhD, LICSW. President, Lighthouse Counseling of Salem, Inc.
Lynn Hill Spragens, MBA. President and CEO Spragens & Associates, LLC.
Jay R. Horton, PhD, ACHPN, FNP-BC, MPH, CENP. Director of Nursing Safety, Quality, and Performance Improvement Mount Sinai Hospital. Assistant Professor Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai.
Khadidjatou Kane, MD. Oncology Hospitalist, Assistant Professor of Hospital Medicine, Northwestern University Feinberg School of Medicine.
Lolita Melhado, MSN, ARNP, FNP-BC. Family Nurse Practitioner/Palliative Care, Gulf Coast Medical Center - Lee Memorial Health System.
Bridget Montana, MSN, APRN, FPCN, MBA. Hope HealthCare Services, Chief Operating Officer.
Colleen Mulkerin, MSW, LCSW. Director Palliative Care Consult Service, Hartford Hospital.
Drew Rosielle, MD, FAAHPM. Palliative Care, Fairview Health Services, University of Minnesota Medical School.
David Weissman, MD. President, Palliative Care Education, LLC.
Amy Case, MD, FAAHPM. Associate Professor of Oncology, Chair, Department of Supportive Care.*
Melissa Bakar, MD. Assistant Professor, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai.*
Elizabeth Mann, MD. Fellow, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai.
*indicates ABIM Peer Reviewer
Delivering Serious News
Communicating serious clinical news to patients and families.
How to discuss patient prognosis in a manner that is sensitive, clear, and supportive.
Clarifying Goals of Care
Strategies for eliciting patient goals and preferences to inform treatment decisions.