Advance Care Planning Conversations
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:
- Case Management: 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)
Tools & Resources
Stepwise approach to discussing advance care planning with patients or surrogates. Center to Advance Palliative Care and VitalTalk.
Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.
One-page reference guide to billing for advance care planning conversations. Center to Advance Palliative Care and Acevedo Consulting, August 2016.
Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.
Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.
Strategies for eliciting patient goals and preferences to inform treatment decisions.
One-page guides with actionable tips for conversations with patients with serious illness. Free to download, print and share with others.
Brief videos to help clinicians hold appropriate conversations with patients about the completion of the POLST form (Physician Orders for Life Sustaining Treatment).
This resource lists step-wise tips to foster comfortable, productive dialogue for ‘the hospice conversation’.
A list of advance care planning conversation tips for care managers.
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.
Diane E. Meier, MD, FACP, FAAHPM
Founder, Director Emerita and Strategic Medical Advisor, 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