Advance Care Planning Model Research Articles

Sharing health care wishes among older adults with cognitive impairment in primary care: Results from a randomized controlled trial.

Best practices for conducting advance care planning (ACP) among persons with cognitive impairment exist, but evidence-based models are lacking for the primary care setting. We tested a remote multicomponent ACP model (SHARE) versus minimally enhanced usual care in 273 person-family dyads from eight primary care practices. Mean patient age was 88.0years, 85 (31.1%) were Black/Latino; 189 (69.2%) had moderate-to-severe cognitive impairment. Most (101/145; 69.6%) intervention dyads engaged in ACP. At follow-up, no treatment effect was observed for care partner-reported quality of communication about end-of-life care at 6 or 12 months, but intervention patients reported better quality of communication about end-of-life care at 12 months. Intervention care partners and patients reported greater readiness to engage in ACP at 6 and 12 months, respectively, and increased completion of key aspects of ACP. SHARE supported key aspects of ACP processes and communication about end-of-life care. Primary care-based models of ACP for persons with dementia are lacking. Involving persons with cognitive impairment in remote ACP is feasible with care partner involvement. Results indicate benefit for aspects of ACP processes and communication about end-of-life care.

Factors Contributing to Non-Concordance Between End-of-Life Care and Advance Care Planning

ContextDespite making do-not-resuscitate or comfort care decisions during advance care planning, terminally ill patients sometimes receive life-sustaining treatments as they approach end of life. ObjectivesTo examine factors contributing to nonconcordance between end-of-life care and advance care planning. MethodsIn this longitudinal retrospective cohort study, terminally ill patients with a life expectancy shorter than six months, who had previously expressed a preference for do-not-resuscitate or comfort care, were followed up after palliative shared care intervention. An instrument with eight items contributing to non-concordant care, developed through literature review and experts’ consensus, was employed. An expert panel reviewed electronic medical records to determine factors associated with non-concordant care for each patient. Statistical analysis, including descriptive statistics and the chi-square test, examines demographic characteristics, and associations. ResultsAmong the enrolled 7871 patients, 97 (1.2%) received non-concordant care. The most prevalent factor was “families being too distressed about the patient's deteriorating condition and therefore being unable to let go” (84.5%) followed by “limited understanding of medical interventions among patients and surrogates” (38.1%), and “lack of patient participation in the decision-making process” (25.8%). ConclusionsThis study reveals that factors related to relational autonomy, emotional support, and health literacy may contribute to non-concordance between advance care planning and end-of-life care. In the future, developing an advance care planning model emphasizes respecting relational autonomy, providing emotional support, and enhancing health literacy could help patients receiving a goal concordant and holistic end-of-life care.

Advance Care Planning in Brazil

Brazil is a country of continental size marked by extreme social inequalities. Its regulation of Advance Directives (AD) was not enacted by law but within the scope of the norms that govern the relationships between patients and physicians, as a resolution of the Federal Medical Council without any specific requirement for notarization. Despite this innovative starting point, most of the debate regarding Advance Care Planning (ACP) in Brazil has been dominated by a legal transactional approach focused on making decisions in advance and the creation of AD. Yet, other novel ACP models have recently emerged in the country with a focus on the creation of a specific quality of relationship between patients, families, and physicians aiming at the facilitating future decision-making. Most of the education on ACP in Brazil happens in the context of palliative care courses. As such, most ACP conversations are performed within palliative care services or by healthcare professionals with training in that area. Hence, the scarce access to palliative care services in the country means that ACP is still rare and that those conversations usually happen late in the course of disease. The authors posit that the existing paternalistic healthcare culture is one of the most important barriers to ACP in Brazil and envision with great concern the risk that its combination with extreme health inequalities and the lack of healthcare professionals’ education on shared decision-making could lead to the misuse of ACP as a form of coercive practice to reduce healthcare use by vulnerable populations.

Advance Care Planning in Serious Illness: A Narrative Review.

Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.

Project DECIDE, part 1: increasing the amount of valid advance directives in people with Alzheimer’s disease by offering advance care planning—a prospective double-arm intervention study

Everybody has the right to decide whether to receive specific medical treatment or not and to provide their free, prior and informed consent to do so. As dementia progresses, people with Alzheimer's dementia (PwAD) can lose their capacity to provide informed consent to complex medical treatment. When the capacity to consent is lost, the autonomy of the affected person can only be guaranteed when an interpretable and valid advance directive exists. Advance directives are not yet common in Germany, and their validity is often questionable. Once the dementia diagnosis has been made, it is assumed to be too late to write an advance directive. One approach used to support the completion of advance directives is 'Respecting Choices'®-an internationally recognised, evidence-based model of Advance Care Planning (ACP), which, until now, has not been evaluated for the target group of PwAD. This study's aims include (a) to investigate the proportion of valid advance directives in a memory clinic population of persons with suspected AD, (b) to determine the predictors of valid advance directives, and (c) to examine whether the offer of ACP can increase the proportion of valid advance directives in PwAD. We intend to recruit at least N = 250 participants from two memory clinics in 50 consecutive weeks. Of these, the first 25weeks constitute the baseline phase (no offer of ACP), the following 25weeks constitute the intervention phase (offer of ACP). The existence and validity of an advance directive will be assessed twice (before and after the memory clinic appointment). Moreover, potential predictors of valid advance directives are assessed. The results of this study will enhance the development of consent procedures for advance directives of PwAD based on the ACP/Respecting Choices(R) approach. Therefore, this project contributes towards increasing the autonomy and inclusion of PwAD and the widespread acceptance of valid advance directives in PwAD. Trial Registration DRKS, DRKS00026691, registered 15th of October 2021, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00026691.

Considerations in the reliability and fairness audits of predictive models for advance care planning.

Multiple reporting guidelines for artificial intelligence (AI) models in healthcare recommend that models be audited for reliability and fairness. However, there is a gap of operational guidance for performing reliability and fairness audits in practice. Following guideline recommendations, we conducted a reliability audit of two models based on model performance and calibration as well as a fairness audit based on summary statistics, subgroup performance and subgroup calibration. We assessed the Epic End-of-Life (EOL) Index model and an internally developed Stanford Hospital Medicine (HM) Advance Care Planning (ACP) model in 3 practice settings: Primary Care, Inpatient Oncology and Hospital Medicine, using clinicians' answers to the surprise question ("Would you be surprised if [patient X] passed away in [Y years]?") as a surrogate outcome. For performance, the models had positive predictive value (PPV) at or above 0.76 in all settings. In Hospital Medicine and Inpatient Oncology, the Stanford HM ACP model had higher sensitivity (0.69, 0.89 respectively) than the EOL model (0.20, 0.27), and better calibration (O/E 1.5, 1.7) than the EOL model (O/E 2.5, 3.0). The Epic EOL model flagged fewer patients (11%, 21% respectively) than the Stanford HM ACP model (38%, 75%). There were no differences in performance and calibration by sex. Both models had lower sensitivity in Hispanic/Latino male patients with Race listed as "Other." 10 clinicians were surveyed after a presentation summarizing the audit. 10/10 reported that summary statistics, overall performance, and subgroup performance would affect their decision to use the model to guide care; 9/10 said the same for overall and subgroup calibration. The most commonly identified barriers for routinely conducting such reliability and fairness audits were poor demographic data quality and lack of data access. This audit required 115 person-hours across 8-10 months. Our recommendations for performing reliability and fairness audits include verifying data validity, analyzing model performance on intersectional subgroups, and collecting clinician-patient linkages as necessary for label generation by clinicians. Those responsible for AI models should require such audits before model deployment and mediate between model auditors and impacted stakeholders.

Integration of Advance Care Planning Into Clinical Practice: A Quality Improvement Project for Leaders.

This quality improvement initiative sought to develop a proactive integrated system approach to advance care planning (ACP) through leadership and colleague engagement. Nurse leaders have the capacity to influence the professional competencies of care teams in ACP. Nurse leaders were educated on the importance of ACP, national quality metrics, resources for staff education, and ways to integrate ACP into workflows based on a population management model. The project design is a prospective, mixed method design. Nurse leader participants demonstrated a significant increase in knowledge of the importance of ACP and evidence-based models to increase staff engagement and competency. Study supports nurse leader interventions, promoted engagement of proactive ACP to honor patient choice, and aligns with the mission and vision of one of the largest national Catholic healthcare organizations of being a trusted partner for life.

Advance care planning: the future

ObjectivesThere is increased global focus on advance care planning (ACP) with attention from policymakers, more education programmes, laws and public awareness campaigns.MethodsWe provide a summary of the evidence about what...

Evaluating Diverse Methodologies and Interventions for Facilitating Advance Care Planning (ACP) Among Seriously Ill Patients: Lessons from Ongoing PCORI-funded ACP Trials (FR415)

•Describe diverse methodologies for implementing interventions to increase advance care planning for seriously ill patients in three PCORI-funded large, multi-site comparative effectiveness trials.•Describe real-world challenges of implementing and evaluating advance care planning interventions for seriously ill patients.•Engage in an interactive activity to identify barriers and solutions to implementing advance care planning in a variety of real-world clinical settings. PCORI recently funded three large, multi-site trials focused on advance care planning (ACP) among seriously ill patients. Each trial takes a unique methodologic approach including different ACP interventions, implementation strategies, and methods for measuring program success. Collectively these trials answer critical questions related to delivery of ACP in real-world settings including identifying the optimal mix of clinicians needed to engage in ACP, evaluating approaches for reducing disparities in ACP and associated outcomes, and understanding the intensity of ACP interventions needed to facilitate optimal patient and caregiver outcomes.•One study is evaluating two different implementation strategies for the Serious Illness Care Program (SICP): primary care clinician-focused versus multidisciplinary team focused, and will enroll over 1,000 patients from 42 primary care clinics in the U.S. and Canada.•A second study is comparing the effectiveness of two ACP interventions (Respecting Choices vs. Five Wishes) in reducing racial disparities in ACP and patient outcomes among 800 seriously ill older adults from 10 clinics in Southern U.S.•A third population-based study is comparing the effectiveness on multi-level outcomes of three ACP interventions that vary in intensity (advance directive alone; advance directive plus the Prepare For Your Care decision support website; advance directive plus PREPARE plus ACP health care navigator facilitation. This study will enroll 6,000 patients with serious illness from 50 primary care clinics in California. In this session, we will review and contrast the variety of ACP models and tools, including supporting evidence, being tested in these studies. We will also explore the different approaches to population selection, ACP implementation and evaluation, and stakeholder engagement taken in these studies. Participants will then be engaged in an interactive exercise to consider how the experience to date in these three trials could inform the implementation of ACP for their own clinics and health systems.

Community-Based Conversations about Advance Care Planning for Underserved Populations Using Lay Patient Navigators.

Background: Widespread community engagement in advance care planning (ACP) is needed to overcome barriers to ACP implementation. Objective: Develop, implement, and evaluate a model for community-based ACP in rural populations with low English language fluency and health care access using lay patient navigators. Design: A statewide initiative to improve ACP setting/subjects-trained in a group session approach, bilingual patient navigators facilitated 1-hour English and Spanish ACP sessions discussing concerns about choosing a surrogate decision maker and completing an advance directive (AD). Participants received bilingual informational materials, including Frequently Asked Questions, an AD in English or Spanish, and Goal Setting worksheet. Measurement: Participants completed a program evaluation and 4-item ACP Engagement Survey (ACP-4) postsession. Results: For 18 months, 74 ACP sessions engaged 1034 participants in urban, rural, and frontier areas of the state; 39% were ethnically diverse, 69% female. A nurse or physician co-facilitated 49% of sessions. Forty-seven percent of participants completed an ACP-4 with 29% planning to name a decision maker in the next 6 months and 21% in the next 30 days; 31% were ready to complete an AD in the next 6 months and 22% in the next 30 days. Evaluations showed 98% were satisfied with sessions. Thematic analysis of interviews with facilitators highlighted barriers to delivering an ACP community-based initiative, strategies used to build community buy-in and engagement, and ways success was measured. Conclusion: Patient navigators effectively engaged underserved and ethnically diverse rural populations in community-based settings. This model can be adapted to improve ACP in other underserved populations.

Integration of an Advance Care Planning Model in Home Health: Favorable Outcomes in End-of-Life Discussions, POLST Rates, and 60-day Hospital Readmissions.

Only 2.3% of patients at a Midwest home healthcare (HH) agency had documented advance directives (ADs), compared with 28% nationally. Of concern, this HH agency lacked standardized procedures for advance care planning (ACP) leading to inadequate staff knowledge regarding end-of-life, avoidable hospital readmissions, and delayed transitions into hospice care. Lack of ADs is directly correlated to higher hospital readmission rates and lower hospice length of stay. The purpose of this initiative was to develop evidence-based procedures using the Respecting Choices ACP model to: 1) educate staff, 2) increase ACP conversations offered and completed among high-risk patients, 3) increase Practitioner Orders for Life-Sustaining Treatment (POLST) rates, 4) reduce 60-day hospital readmissions, and 5) support hospice care admissions. Staff received discipline-specific education on ACP/ADs. The Knowledge-Attitudinal-Experiential Survey on Advance Directives (KAESAD), assessed staff ACP/AD knowledge, confidence, and experiences. Standardized electronic medical record tools were created to track ACP conversations, POLST rates, 60-day hospital readmissions, and hospice admissions. Paired t-test and chi-square analyses compared changes pre- and post implementation. The KAESAD survey was analyzed for 75 staff (100%) and demonstrates improvement in knowledge, confidence, and experiences. Data also demonstrate increases in: ACP offered 6% to 80% (p < .001); ACP conversations completed 4% to 31% (p < .001); POLST rates 26% to 43.6% (p = .059); decreased 60-day hospital readmissions 40% to 20% (p = .025); whereas hospice care admissions was not impacted ranging from 10% to 5.5% (p = .381). Respecting Choices serves as an effective ACP framework to improve ACP conversations, POLST rates, and hospital readmissions.

Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis

ObjectivesHow advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice...

Disease-Specific Advance Care Planning Interventions for Older Adults

Advance care planning is beneficial but underutilized for older patients with dementia, cancer, end-stage renal disease, lung disease, or heart failure. The purpose of this paper is to highlight recent disease-specific innovations aimed at improving the delivery of advance care planning for older adults. We highlight 13 studies within the last 5 years focusing on advance care planning models in older adults with the above diseases. Useful interventions include incorporation of non-physician facilitators, varying platforms of ACP delivery, surrogate participation, and written communication of patient preferences to other providers. Several existing models were applicable across disease types. Further research comparing advance care planning models in older adults is warranted.

Palliative care related hotspots and visualized analysis based on Web of Science

Objective To analyze SCI papers related to palliative care and identify research hotspots to offer theoretical guidance and basis for further research and management of palliative care. Methods SCI papers related to palliative care published on Web of Science from 1994 to 2017 were taken as the data source. Classified statistics, bibliometrics and CiteSpace II visualization software were used for relevant description and graphing. Results The number and the cites of published SCI papers on palliative care began to rise substantially since 1994; the US ranked first in terms of the number of published papers, which was followed by China. Totally 24 high frequency keywords and 20 burst terms (research fronts) were found. The results showed that the subject of palliative care research turned from terminal stage patients to specific patients with chronic diseases and medical and nursing workers; psychological problems such as depression and sorrow in family care givers should draw more attention, and problem of races became a tendency as well. Conclusions Palliative care related research has drawn attention from scholars at home and abroad. China's research in palliative care has a late start and remains in its infancy. Our scholars can use the experience of other countries as well as the advance care planning model of Taiwan Region of China for reference so as to find a palliative care model which is suitable for our conditions. Key words: Nursing; Palliative care; Research hotspots; Visualized analysis

Social and structural conditions for the avoidance of advance care planning in neuro-oncology: a qualitative study

BackgroundPrimary brain tumours newly affect >260 000 people each year worldwide. In the UK, every year >10 000 people are diagnosed with a brain tumour while >5000 die annually from...

Respecting Choices and Related Models of Advance Care Planning: A Systematic Review of Published Evidence.

All individuals should receive care consistent with their expressed preferences during serious and chronic illnesses. Respecting Choices (RC) is a well-known model of advance care planning intended to assist individuals consider, choose, and communicate these preferences to health-care providers. In this systematic review, we evaluated the published literature on the outcomes of the RC and derivative models utilizing criteria developed by the Cochrane Collaborative. Eighteen articles from 16 studies were included, of which 9 were randomized controlled trials, 6 were observational, and 1 was a pre-posttest study. Only 2 specifically included a minority population (African American). Fourteen were conducted in the United States, primarily in the Wisconsin/Minnesota region (n = 8). Seven studies examined the RC model, whereas 9 examined derivative models. There was significant heterogeneity of outcomes examined. We found that there is a low level of evidence that RC and derivative models increase the incidence and prevalence of Advance Directive and Physician Orders for Life-Sustaining Treatment completion. There is a high level of evidence that RC and derivative models increase patient-surrogate congruence in Caucasian populations. The evidence is mixed, inconclusive, and too poor in quality to determine whether RC and derivative models change the consistency of treatment with wishes and overall health-care utilization in the end of life. We urge further studies be conducted, particularly with minority populations and focused on the outcomes of preference-congruent treatment and health-care utilization.

Advance Care Planning for Patients with End-Stage Renal Disease.

Advance care planning (ACP) may seem straightforward to some. However, for many people this is a challenging topic to discuss and a complex landscape to navigate. This work can be time consuming and emotionally charged, requiring the collaboration of several team members for positive outcomes to result. As a renal social worker in an acute care setting, I see ACP surfacing frequently as a discussion topic. I have seen cases ranging from patients not participating in any ACP to very detailed ACP documentation. This Viewpoint will discuss ACP, explore both the negatives and positives of ACP, and focus in on a study that found a certain model for ACP to be successful. Throughout this text, I will reference the case of Ms. B to help further demonstrate that ACP is a valuable tool for patients with chronic kidney disease, despite some challenges and drawbacks. When working with these patients, the aim is to protect and promote patient autonomy during times of high vulnerability.

What do patients with cancer and their families value most at the end of life? A critical analysis of advance care planning.

Advance care planning (ACP) is defined in a variety of ways, although it is widely understood as a process undertaken by patients, when they have capacity, to define and communicate their treatment preferences for future care. Few studies have explored the meaning and importance patients place on their ability to participate in directing their medical care. This study aimed to explore how cancer patients and their family members value autonomy at the end of life (EoL) and understand how this may impact on the way they develop and act on EoL decisions and planning. Data were collected through in-depth semi-structured interviews with patients and family members of people with cancer. Participants were recruited from metropolitan cancer centres in Sydney, Australia. Interviews were analysed using thematic analysis. Findings from 11 participant interviews (five patients with cancer and six family members) were organised into four themes: 'the threat of death and cancer'; 'patients seek trust and safety at the end of life'; 'doctors are human and the healthcare system has limitations'; and 'the role of ACP'. Participants experienced cancer and death as a 'threat', to self and others and as something 'uncontrollable'. ACP was seen to have the potential to enhance EoL care by contributing to decreasing uncertainty, enhancing comfort, helping to achieve 'the small things', and in helping the family 'know what to do'. However, participants were, in general, distrustful of documentation and cognisant of uncertainty around medical outcomes and the legal limitations of their capacity to influence care. These findings suggest that models of ACP which are constructed around patients' 'rights' to determine what happens to their bodies may do little to enhance the quality of EoL care, as patients value veracity, trust and comfort at the EoL more than autonomy. Quality EoL care should focus on paying increased attention to the relational and social aspects of care.

Clinicians’ Perspectives on Advance Care Planning for Patients With CKD in Australia: An Interview Study

Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, ACP is not widely implemented in chronic kidney disease (CKD) care settings. This study aims to describe clinicians' beliefs, challenges, and perspectives of ACP in patients with CKD. Qualitative study. Nephrologists (n=20), nurses (n=7), and social workers (n=4) with a range of experience in facilitating ACP for patients with CKD across Australia. Semistructured interviews were digitally recorded and transcribed verbatim. Transcripts were analyzed using thematic analysis. 5 major themes were identified: facilitating informed decision making (avoiding preconceptions, conveying complete truths, focusing on supportive care, and synchronizing with evolving priorities), negotiating moral boundaries (contending with medical futility and respecting patient vs family autonomy), navigating vulnerable conversations (jeopardizing the therapeutic relationship, compromising professional confidence, emotionally invested, and enriching experiences), professional disempowerment (unsupportive culture, doubting logistical feasibility, and making uncertain judgments), and clarifying responsibilities (governing facilitation, managing tensions, and transforming multidisciplinary relationships). Some findings may be specific to the Australian context. The tensions among themes reflect that ACP is paradoxically rewarding for clinicians because ACP empowers patients yet can expose personal and professional vulnerabilities. Clinicians believe that a more collaborative approach is needed, with increased efforts to identify the evolving and individualized needs and goals of patients with CKD. Models of ACP that address clinicians' personal and professional vulnerabilities when initiating ACP may foster greater confidence and cultural acceptance of ACP in the CKD setting.

Managing \u2018shades of grey\u2019: a focus group study exploring community-dwellers\u2019 views on advance care planning in older people

BackgroundCommunity-dwelling consumers of healthcare are increasing, many aging with life-limiting conditions and deteriorating cognition. However, few have had advance care planning discussions or completed documentation to ensure future care preferences are acted upon. This study examines the awareness, attitudes, and experiences of advance care planning amongst older people and unrelated offspring/caregivers of older people residing in the community.MethodsQualitative descriptive research, which included focus groups with older people (55+ years) and older people’s offspring/caregivers living in an Australian city and surrounding rural region. Data was analysed using an inductive and comparative approach. Sampling was both convenience and purposive. Participants responded to web-based, newsletter or email invitations from an agency, which aims to support healthcare consumers, a dementia support group, or community health centres in areas with high proportions of culturally and linguistically diverse community-dwellers.ResultsEight focus groups were attended by a homogenous sample of 15 older people and 27 offspring/caregivers, with 43% born overseas. The overarching theme, ‘shades of grey’: struggles in transition, reflects challenges faced by older people and their offspring/caregivers as older people often erratically transition from independence and capacity to dependence and/or incapacity. Offspring/caregivers regularly struggled with older people’s fluctuating autonomy and dependency as older people endeavoured to remain at home, and with conceptualising “best times” to actualise advance care planning with substitute decision maker involvement. Advance care planning was supported and welcomed, x advance care planning literacy was evident. Difficulties planning for hypothetical health events and socio-cultural attitudes thwarting death-related discussions were emphasised. Occasional offspring/caregivers with previous substitute decision maker experience reported distress related to their decisions.ConclusionsAdvance care planning programs traditionally assume participants are ‘planning ready’ to legally appoint a substitute decision maker (power of attorney) and record end-of-life treatment preferences in short time frames. This contrasts with how community dwelling older people and offspring/caregivers conceive future care decisions over time. Advance care planning programs need to include provision of information, which supports older people’s advance care planning understanding and management, and also supports offspring/caregivers’ development of strategies for broaching advance care planning with older people, and preparing for potential substitute decision maker roles. Development and integration of strategies to support older people’s decision-making when in the ‘grey zone’, with fluctuating cognitive capacities, needs further consideration. Findings support an advance care planning model with conversations occurring at key points across a person’s lifespan.