Advance Care Planning Conversations

Last Reviewed: December 6, 2019

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

Only CAPC members who are logged in can earn the following free Continuing Education Credits:

0.50 AMA PRA Category 1 Credit(s)™
Case Management: 1.00 CE
Nursing: 1.00 CNE
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

MEMBERS ONLY

Last Updated: August 16, 2021

Stepwise approach to discussing advance care planning with patients or surrogates. Center to Advance Palliative Care and VitalTalk.

Billing and Coding for Advance Care Planning (ACP) Services

MEMBERS ONLY

Last Updated: February 28, 2019

Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.

Billing the Physician Fee Schedule for Advance Care Planning Services

MEMBERS ONLY

Last Updated: January 29, 2019

One-page reference guide to billing for advance care planning conversations. Center to Advance Palliative Care and Acevedo Consulting, August 2016.

Optimizing Billing Practices

Last Updated: December 20, 2022

Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.

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Communication Phrases in Palliative Care

MEMBERS ONLY

Last Updated: January 29, 2019

Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.

Clarifying Goals of Care

Last Updated: December 6, 2019

Strategies for eliciting patient goals and preferences to inform treatment decisions.

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VitalTalk - Quick Guides

Last Updated: January 29, 2019

One-page guides with actionable tips for conversations with patients with serious illness. Free to download, print and share with others.

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POLST Training Videos

Last Updated: September 29, 2020

Brief videos to help clinicians hold appropriate conversations with patients about the completion of the POLST form (Physician Orders for Life Sustaining Treatment).

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Talking with Patients About Hospice

Last Updated: February 2, 2021

This resource lists step-wise tips to foster comfortable, productive dialogue for ‘the hospice conversation’.

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Key Takeaways for Care Managers: Advance Care Planning Conversations

MEMBERS ONLY

Last Updated: February 24, 2022

A list of advance care planning conversation tips for care managers.

Sample Script and Guidance: Cold-Calling Patients to Initiate Advance Care Planning

MEMBERS ONLY

Last Updated: August 2, 2021

This script for care managers provides guidance and sample language to use when calling without a prior relationship to begin advance care planning for patients with serious illness.

Empathetic Responses Guide

MEMBERS ONLY

Last Updated: November 21, 2022

This resource provides practical samples of empathic responses to use in conversations with patients and families, as well as template responses to challenging questions. Developed by VitalTalk.

Course Directors

Course Faculty

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.

Peer Reviewers

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

Contact information: For answers to frequently asked questions about CAPC courses, read the Online Course FAQ. For technical questions about course activity, email membership@capc.org. For questions about continuing education credits, contact 201-957-0077.