ABOUT US > What is Advance Care Planning?

Advance Care Planning is thinking about how we would like to be treated if ill health means we can’t tell someone how we wish to be treated, and then communicating that plan to someone else.  An accident or disease or aging might make us unable to communicate our wishes at that time, which is why it makes sense to do in advance.  Having a plan is crucial to help doctors, families and friends do what we wish rather than having to guess at what kind of care we might want.

Advance Care Planning is an outgrowth of the palliative care and hospice movements. Originally, palliative care focused on providing a dignified, empowered dying process with well-controlled pain.  With the increasing availability of sophisticated but sometimes burdensome life support technologies and treatments, palliative care has expanded to include discussions and planning with patients to empower them to make decisions about the intensity of care at all stages of life.  Advance Directives, Healthcare Agents, Chronic Disease Management, and POLST forms are Advance Care Planning tools that help ensure our healthcare preferences are known and honored at all life stages.

Different phases in our lives require different approaches to Advance Care Planning:
  • PHASE 1: A written Advance Directive is appropriate for any reasonably healthy adult, 18 years of
    age and older. An Advance Directive indicates our wishes and preferences for life-sustaining
    healthcare in the event of a critical medical situation in which we are unable to communicate our
    wishes. Phase I Advance Care Planning also includes selection of a Healthcare Agent, someone we
    trust to advocate for us and make healthcare decisions on our behalf if we are incapacitated.
    Ideally, Advance Directive discussions will be initiated by primary care providers during routine
    health maintenance visits.

  • PHASE 2:  Additional Advance Care Planning is indicated for all individuals with chronic, progressive illnesses who are at risk of complications that could leave them unable to make their own healthcare decisions. Trained facilitators may lead this process as part of Chronic Disease Management, incorporating a new or revised Advance Directive and including the designated Healthcare Agent. Phase 2 planning helps individuals understand the progression of their illness and potential complications, as well as the potential benefits and burdens of life-sustaining treatments and palliative care alternatives.                                                                                             

  • PHASE 3: Focused and detailed Advance Care Planning is indicated for individuals with a prognosis of one year or less to live, very frail elderly patients, and frail patients living in a long-term care facility. Phase 3 includes completion of a Physicians Order for Life Sustaining Treatment (POLST) and an up-to-date Advance Directive with a designated Healthcare Agent. The Advance Directive specifies a patient's wishes regarding cardio-pulmonary resuscitation, intubation, nutrition and hydration, and comfort-care measures. The POLST and Advance Directive help ensure a patient's wishes are incorporated into their provider's medical orders if a critical or terminal event occurs.

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