The 2015 landmark report, DYING IN AMERICA Improving Quality and Honoring Individual Preferences Near the End of Life, reported poor communication quality between clinicians and patients with advanced illness.1 This report, along with the President's Council on Bioethics and many medical and legal organizations, highlighted the importance of advance care planning (ACP) and advance directives (ADs), emphasizing patient values, goals, and preferences.2 Despite considerable effort, however, implementation of ACP using ADs has not improved serious illness communication nor improved end-of-life care in the U.S.3-10 One reason ADs have fallen short is that AD documents have little relevance in routine clinical care. A second is that ADs have little relevance in acute “in-the-moment” decision-making, where goals-of-care discussions and treatment decisions occur. Third, ADs have little relevance to the clinical uncertainty, complexity and emotional dynamics frequently present in the acute setting of serious illness. Fourth, for any person, in ordinary health or seriously ill, it is difficult to consider a future hypothetical event, articulate specific values, goals, and preferences, and then commit to future decisions. Advance directive is not a precise term. It actually refers to two very different ACP documents in the legal code of most states. The first is the living will, also called declaration of desire for a natural death. The second is the healthcare power of attorney (HCPOA). The former is for a person preparing for the remote and rare event of becoming “terminal” or permanently unconscious, while the latter is for every adult at any time. The living will asks people to forgo, or not, a number of medical procedures they may not know much about or understand, such as cardiopulmonary resuscitation (CPR), mechanical ventilator, and PEG (percutaneous endoscopic gastrostomy) tube. The living will also contains intimidating, legal language, requires a patient's signature, and often focuses on tangents such as nutrition and hydration. For both the living will and the HCPOA, policies, procedures, and statutes exist to allow healthcare providers to “make do” when a person does not have an ACP document. Both are underutilized and rarely viewed by anyone after signing. Since the Patient Self Determination Act (PSDA) mandate in 1990, hospitals in the U. S. have implemented procedures to ask every person being admitted if they “have an advance directive.”11 Over the years, hospitals, doctors, nurses, patients, families and caregivers have all come to realize that the answer, yes or no, makes little difference in one's care. Many, if not most, people in good health or with serious illness engage the healthcare system hoping and anticipating continuing to live, even in the event of hospitalization, and even in the event of intensive care. When patients encounter a change in outpatient status that brings them to the emergency department or a change in inpatient status that brings the rapid response team to their room, the living will may very well be unavailable or inapplicable. The usual and understandable priority is to “do something” to “get better,” such that acute “in-the-moment” decision-making usually occurs urgently, with only rare consultation of an AD. Acute “in-the-moment” medical decision-making for people with serious illnesses is uniquely complex for each person. At a minimum, these decisions require estimating likelihood of desired or undesired outcomes; understanding medical terminology, human physiology, the natural history of the illness, benefits and risks; recalibrating expectations and hopes; and managing strong emotions of fear, loss, anger, and grief.4, 5, 7, 8 This complexity particularly challenges the practicality and utility of “advance” directives. Stories of individuals living in prolonged unconsciousness with medical support, such as Karen Quinlan and Nancy Cruzan, captured the public and political imagination in the 1980s. These cases prompted state legislatures to pass “declaration of desire for a natural death” laws that allow a person to direct future medical providers to withdraw medical support in such a situation. Unfortunately, this binary withdraw-care-in-a-coma-or-not directive is almost entirely inadequate to address the myriad of complexities of medical decision-making or the many nuances of an individual's illness and circumstances. Patients and care partners facing acute serious illness are understandably and frequently dismayed when asked to consider their values, goals, and preferences and then to make this binary decision about their care in a hypothetical future prolonged unconsciousness or inability to consent. There is certainly a group of severely ill people, such as those with limited performance status and limited prognosis under hospice care, who have goals of care (GOC) limited to remaining comfortable in their current setting and clearly do not want to be hospitalized or receive intensive care. For these individuals, most states have portable emergency medical services (EMS) do not resuscitate (DNR) documents that allow them to direct healthcare providers in advance to limit care. The paradigm change from advanced care planning to serious illness communication is long overdue. The best path forward for serious illness communication is to deemphasize ADs and to emphasize patient activation (PA), including engaging a surrogate decision-maker. While the goal of ADs is to achieve concordant care near end of life for patients who lack decisional capacity, the aim of patient activation is to increase the patient's and care partner's understanding of their role in the care process, and provide them with the knowledge, skill and confidence to articulate their needs, navigate the health system, and manage the illness.12 Naming a HCPOA helps PA by adding a trusted person to learn, navigate and make decisions along with the patient. Across a wide range of settings and social determinants of health, PA is associated with favorable health outcomes and patient experience. PA can be measured, and interventions can improve PA. “The paradigm change from advance care planning to serious illness communication is long overdue. The best path forward for serious illness communication is to deemphasize ADs and to emphasize patient activation (PA), including engaging a surrogate decision maker.” The advance directive (living will) and patient activation are distinct in multiple ways (see Table 1). ADs involve consideration of unappealing, hypothetical circumstances, while PA is focused on the patient's present illness. ADs look to an unappealing, remote future, while PA is centered on the here and now. ADs consider events at an unspecified location, while patient activation encourages immediate engagement with the health care team for both the patient and care partner. ADs ask the patient to commit to a decision with limited information while PA equips the patient and care partner to assimilate information and to make good decisions when the need arises. Gaps in knowledge and understanding between providers, patients, families, and caregivers are common. Medical provider stress and burnout are prevalent. Cumbersome electronic medical records (EMRs) are ubiquitous. Bureaucratic healthcare systems are widespread. These system-level issues frequently result in low value care, which leads to frustration, professional dissatisfaction, and moral injury for the nurses, doctors and staff who end up providing the low value care. The cognitive dissonance between the providers' professional expectations for the care of their patients and the care that they find themselves providing contributes substantially to provider burnout.9, 13-15 Three steps are critical to improve serious illness communication and the patient, family, and care partner experience (see Figure 1). First, the healthcare team should activate patients and care partners to ask questions and to understand the seriously ill person, the illness, and the healthcare system, and to support the seriously ill person coping with the difficult illness experience. Second, the healthcare team should empower the patient, family, friends, and caregivers to navigate the care of the seriously ill person. This means to speak up for the patient, to know where and how to ask for help and to advocate for the patient. Information and preparation can help the activated patient and family anticipate and manage the acute “in-the-moment” decision-making that inevitably occurs. Facilitating ongoing interaction and communication with providers can improve the patient, caregiver and, perhaps, even the provider experience in end-of-life care.16 Third, the health care system should design care delivery to facilitate sequential serious illness goals of care (GOC) conversations and to document these conversations consistently in the EMR.17 GOC conversation documentation must become a part of the medical culture, such that the various physician and nursing providers, patients, families, and caregivers are able to readily know and understand each other, as well as the patient's understanding of the GOC. Amazing technology, new treatments, raised expectations, and changing demographics continue to evolve and challenge the delivery of medical care for the seriously ill near the end of life. Most end-of-life palliative care is “primary,” that is, provided by non-specialty medical providers who care for the seriously ill in the hospital, nursing facility, medical office, or home. In short, the health system needs to better understand the seriously ill patient and the patient needs to better understand the workings of the health system. The need to improve the care of people with serious illnesses is urgent for patients and care partners, for medical providers, and for health systems. Advance care planning needs to evolve to serious illness communication to improve end-of-life care for the seriously ill. A patient activation approach to serious illness communication is the paradigm change that has great potential to improve care across a health system.18 Creating health systems that support connection and communication among seriously ill people and their medical providers can promote both diagnostic excellence19 and the quadruple aim of health care: quality care, population health, affordable cost, and healthcare team well-being.20 Let us move forward, activate, and set aside the living will. Each of the three authors contributed to the ideas, writing, and content. No specific funding was received for this work. No conflict of interest for any of the three authors. No sponsor, therefore no role.