Value Of Advance Care Planning Research Articles

"At the End I Have a Say": Engaging the Chinese Community in Advance Care Planning.

Despite the association of advance care planning (ACP) with improved patient and caregiver outcomes, Chinese American elders have low rates of ACP. Assess ACP facilitators/barriers in the San Francisco (SF) Chinese community and codesign, implement, and test community-based ACP-promoting pilot events. A Chinese Community Committee (N=19 community-based organization leaders, health system representatives, community members) conducted focus groups in Cantonese and English with Chinese older adults (age ≥55), caregivers, and community leaders. The Committee designed and implemented pilot events in-person and online. We analyzed focus group data using thematic analysis; assessed pre-to-post-event readiness to engage in ACP (validated survey; 14 scale, 4=most ready); and assessed event acceptability. A total of 34 people participated in six focus groups. Themes described Chinese community-specific importance of ACP (e.g., reduces family burden), barriers (e.g., younger generations lack tools to discuss ACP with elders and vice versa), and facilitators (e.g., intergenerational events, culturally/linguistically appropriate materials). Based on focus groups findings, the Committee developed a novel ACP tool and designed intergenerational events. A total of 195 participants attended 10 events; 95% were Chinese, 90% spoke Chinese languages, 80% were women. ACP readiness increased significantly (1.66 [SD 0.84] vs. 2.03 [SD 0.85]; P < 0.001); 94% of participants were comfortable attending and 96% would recommend events. Community-developed intergenerational events that highlight the value of ACP and address barriers are acceptable and increase ACP engagement in the Chinese community.

Advance Care Planning in the United Kingdom – A snapshot from the four UK nations

The United Kingdom (UK) as a whole has a long-established decades-old history as an early adopter of the concepts of Advance Care Planning (ACP), with significant integration into mainstream national policy and widespread implementation. The ACP term itself, its processes, means, inclusions and implementations vary considerably within the UK and between its four nations, but the overall impression is of a strongly uniting consensus on the positive impact, value and vital importance of ACP in enabling better care for people in the final years of life, and at earlier life stages. Though there is always more work to do and more lessons to learn, those of us who have watched this world-wide movement grow over recent decades, find the overall direction of travel of commitment to mainstreaming ACP in the UK to be inspiring and encouraging, and gives us hope for the future. Across the UK, there is much shared history, policy, objectives, and regulation related to ACP, and at the same time, many variations in approach, tone, emphasis and detail within and between the four nations of the UK. The 2022 Office of National Statistics reports that the four nations of the UK have a combined population of 67 million (England 56.5 million, Scotland 5.5 million, Wales 3.1 million, Northern Ireland 1.9 million). All four nations are prioritising ACP as part of national policy, aiming to deliver more personalised care, particularly but not exclusively for those nearing the end of life, with a wide variety of best practice examples. Here we describe some common areas and variations across the UK history, policy and legal perspectives, some examples of best practice, resources, and exciting developments across all four nations which, although not exhaustive and within the limitations of our brief, reflect the flavour of our shared commitment. We are most grateful to all the contributing authors.

Experiences with and perspectives on advance care planning in young- and late- onset dementia: A focus group study with physicians from various disciplines.

Despite the relevance of advance care planning (ACP) for people with dementia, its uptake in this population is particularly low. Several challenges for ACP in dementia have been identified from physicians' perspectives. However, the literature available mainly includes general practitioners and focuses exclusively on the context of late-onset dementia. This is the first study to inquire physicians from four highly relevant specialisms in dementia care, with a focus toward potential specificities based on patients' age. The research question of this study is: "What are physicians' experiences with and perspectives on discussing ACP with people with young- and/or late-onset dementia?". Five online focus groups were conducted with 21 physicians (general practitioners, psychiatrists, neurologists and geriatricians) in Flanders, Belgium. Verbatim transcripts were analyzed through the qualitative method of constant comparative analysis. Physicians believed that the societal stigma related to dementia influences people's reaction to their diagnosis, at times characterized by catastrophic expectations for the future. In this regard, they explained that the topic of euthanasia is sometimes addressed by patients very early in the disease trajectory. Respondents paid ample attention to actual end-of-life decisions, including DNR directives, when discussing ACP in dementia. Physicians felt responsible for providing accurate information on both dementia as a condition, and the legal framework of end-of-life decisions. Most participants felt that patients' and caregivers' wish for ACP was more driven by who their personality than by their age. Nonetheless, physicians identified specificities for a younger dementia population in terms of ACP: they believed that ACP covered more domains of life than for older persons. A high consistency regarding the viewpoints of physicians from differing specialisms was noted. Physicians acknowledge the added value of ACP for people with dementia and especially their caregivers. However, they face several challenges for engaging in the process. Attending to specific needs in young-onset, in comparison to late-onset dementia, requires ACP to entail more than solely medical domains. However, a medicalized view on ACP still appears to be dominant in practice as opposed to its broader conceptualization in academia.

An age-friendly population health dashboard geolocating by clinical and social determinant needs.

An age-friendly population health dashboard geolocating by clinical and social determinant needs.

Three Stories About the Value of Advance Care Planning

Three Stories About the Value of Advance Care Planning

Is there a need for advance care planning in China?-an interview survey of healthcare professionals in the neurology department.

Family-oriented medical decision-making in China is founded on Confucian family-determination. The value and necessity of individual autonomy are marginalized in theory and practice. However, the dilemma in end-of-life (EOL) decision-making caused by the lack of advance care planning (ACP) has been increasingly concerned by the public. This study explores the value and necessity of ACP practice in China from the perspective of healthcare professionals (HCPs). We conducted semi-structured interviews with five neurological physicians and five neurological nurses from a Grade 3 Class A hospital in Beijing. The results showed that in situations with a poor prognosis, respondents tended to believe that as part of ACP regarding, a patient's right to refuse invasive treatments should be followed, although all ten interviewees agreed that nasogastric feeding tubes (NGTs) should be maintained. Factors influencing a families' considerations in EOL decision making included prognosis and age, prior similar experiences, others' moral judgement, and the advice of HCPs. Four respondents had experienced patients expressing their wishes for EOL treatments and reported some obstacles in considering these wishes. Seven respondents considered creating an ACP themselves, two respondents doubted it would work in practice, and one respondent thought it was unnecessary. The differences in the concept and practice of palliative care may be significantly related to the differences in the idea of ACP between Chinese and Western. The family-oriented decision-making model under Confucian culture cannot replace the ACP practice. Clinical situations and therapeutic measures that reveal the necessity and value of ACP should be the priority exploration to advance ACP practice. The practice of ACP and palliative care should be promoted simultaneously at the national level, and legislation for advance directives (ADs) is necessary for mainland China.

A cost-consequence analysis of normalised advance care planning practices among people with chronic diseases in hospital and community settings

BackgroundA growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients’ wishes and satisfaction with care, and quality of care for patients and their families. Economic analyses of ACDs and ACP have been more sporadic and inconclusive. This study aimed to contribute to the evidence on resource use associated with implementation of ACP and to inform key decision-makers of the resource implications through the conduct of a cost-consequence analysis of the Normalised Advance Care Planning (NACP) trial.MethodsThe outcomes for the economic evaluation included the number of completed “legally binding” ACDs and the number of completed Conversation Cards (CC). The cost analysis assessed the incremental difference in resource utilisation between Usual Practice and the Intervention. Costs have been categorised into: 1) Contract staff costs; 2) Costs associated with the development of the intervention; 3) Implementation costs; 4) Intervention (delivery) costs; and 5) Research costs.ResultsThe cost incurred for each completed ACD was A$13,980 in the hospital setting and A$1248 in the community setting. The cost incurred for each completed Conversation Card was A$7528 in the hospital setting and A$910 in the community setting.ConclusionsThe cost-consequence analysis does not support generalisation of the specified intervention within the hospital setting. The trial realised an estimated incremental cost per completed ACD of $1248, within the community setting. This estimate provides an additional benchmark against which decision-makers can assess the value of either 1) this approach towards the realisation of additional completed ACDs; and/or 2) the value of ACP and ACDs more broadly, when this estimate is positioned within the potential health outcomes and downstream health service implications that may arise for people with or without a completed ACD.Trial registrationThe study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246). The URL of the trial registry record.

Advance Care Planning in Older Adults with CKD: Patient, Care Partner, and Clinician Perspectives.

Older patients with advanced CKD are at high risk for serious complications and death, yet few discuss advance care planning (ACP) with their kidney clinicians. Examining barriers and facilitators to ACP among such patients might help identify patient-centered opportunities for improvement. In semistructured interviews in March through August 2019 with purposively sampled patients (aged ≥70 years, CKD stages 4-5, nondialysis), care partners, and clinicians at clinics in across the United States, participants described discussions, factors contributing to ACP completion or avoidance, and perceived value of ACP. We used thematic analysis to analyze data. We conducted 68 semistructured interviews with 23 patients, 19 care partners, and 26 clinicians. Only seven of 26 (27%) clinicians routinely discussed ACP. About half of the patients had documented ACP, mostly outside the health care system. We found divergent ACP definitions and perspectives; kidney clinicians largely defined ACP as completion of formal documentation, whereas patients viewed it more holistically, wanting discussions about goals, prognosis, and disease trajectory. Clinicians avoided ACP with patients from minority groups, perceiving cultural or religious barriers. Four themes and subthemes informing variation in decisions to discuss ACP and approaches emerged: (1) role ambiguity and responsibility for ACP, (2) questioning the value of ACP, (3) confronting institutional barriers (time, training, reimbursement, and the electronic medical record, EMR), and (4) consequences of avoiding ACP (disparities in ACP access and overconfidence that patients' wishes are known). Patients, care partners, and clinicians hold discordant views about the responsibility for discussing ACP and the scope for it. This presents critical barriers to the process, leaving ACP insufficiently discussed with older adults with advanced CKD.

Enabling Advance Care Planning in Dementia Care: A Primary Care Approach.

Lack of tools to support advance care planning (ACP) has been identified as a significant barrier to implementing these discussions. We pilot tested an ACP framework tool for use with persons living with dementia (PLWD) in primary care-based memory clinics and an Adult Day Program; this study describes user and recipient experiences with this framework. We used a mixed methods approach. Health professionals completed an online survey following pilot testing and PLWD and substitute decision makers (SDM) completed survey immediately following the ACP discussion assessing their satisfaction (5-point scale) with the framework and exploring potential outcomes. Interviews with health professionals, PLWD, and SDM were conducted to gather more in-depth information on their perceptions of the ACP framework/ discussion. Surveys were completed by 12 health professionals, 13 PLWD, and 16 SDM. While PLWD and SDM were satisfied with the ACP discussion (M = 4.0/5), health professionals were minimally satisfied with the ease of use of the framework (M = 2.0/5), acceptability for patients (M = 2.4/5) and feasibility in practice (M = 1.9/5). Sixteen interviews were completed with 8 health professionals, 1 PLWD, and 7 SDM. While health professionals valued ACP, lack of time and training were identified barriers to framework use. SDM felt better prepared for future decisions and PLWD were put at ease, knowing that their wishes for care were understood. PLWD and SDM value the opportunity for ACP, and although health professionals identified some concerns with framework administration, they acknowledge the value and importance of ACP. Continuing efforts to refine ACP processes are justified.

Low Skepticism and Positive Attitudes About Advance Care Planning Among African Americans: a National, Mixed Methods Cohort Study.

African Americans have low engagement in advance care planning (ACP). This has been attributed to healthcare distrust and skepticism about ACP. A better understanding of these attitudes is needed to address health disparities related to end-of-life care. To explore the ACP-related values and beliefs of diverse African American communities across the USA and then the perceived value of an inexpensive end-of-life conversational game. Prospective, convergent, mixed methods cohort study involving fifteen underserved, African American communities across the USA. Of the 428 who attended events at purposively sampled sites, 90% consented to the research; 37% participated in one of 15 focus groups (n = 141). An end-of-life conversation game, played in groups of 4-6. The validated, 7-item ACP values and beliefs questionnaire (scaled 7 = least skeptical, 49 = most skeptical) was administered pre-game. Post-game focus groups explored perceptions about ACP and the intervention. Participants had positive attitudes (low skepticism) about ACP with a median score of 12.00 (7.00, 20.00). Values and beliefs did not significantly differ by geographical region; however, rural areas were observed to be slightly more skeptical than urban areas (median score 14.00 vs. 11.00, p = 0.002). Themes from focus groups converged with survey data showing participants valued the ACP process and consider further engagement in ACP to be worthwhile. Subthemes emphasized the need for and value of ACP. Skepticism about ACP may contribute to low rates of ACP engagement in underserved African American communities. The positive attitudes uncovered in our study either negate previous findings or suggest reduced skepticism. This study has been registered at clinicaltrials.gov ( NCT03456921 ).

Anxious, Depressed, and Planning for the Future: Advance Care Planning in Diverse Older Adults.

To determine whether depression and anxiety are associated with advance care planning (ACP) engagement or values concerning future medical care. Cross-sectional. English- and Spanish-speaking patients, aged 55 years and older, from a San Francisco, CA, county hospital. Depression was measured by the Patient Health Questionnaire 8-item scale, and anxiety was measured by the Generalized Anxiety Disorder 7-item scale, using standardized cutoffs of 10 or more for moderate-to-severe symptoms. ACP engagement was measured using validated surveys of ACP behavior change (e.g., self-efficacy and readiness; mean five-point Likert score) and ACP actions (e.g., ask, discuss, and document wishes; 0- to 25-point scale), with higher scores representing higher engagement. In addition, we asked a question about valuing life extension ("some health situations would make life not worth living"). We used adjusted linear and logistic regression. Mean age of 986 participants was 63 years, 81% were non-White, 39% had limited health literacy, 45% were Spanish speaking, 13% had depression, and 10% had anxiety. After adjustment for demographic and health status variables, participants who were depressed versus not depressed had higher ACP behavior change scores (0.2 points; 95% confidence interval (CI) = 0.06-0.38; P = .007), higher ACP action scores (1.5 points; 95% CI = 0.51-2.57; P = .003), and higher odds of not valuing life extension (odds ratio (OR) = 2.5; 95% CI = 1.5-4.3; P < .001). Results were similar in participants with versus without anxiety (ACP behavior change: 0.2 points; 95% CI = 0.05-0.40; P = .01; ACP action scores: 1.2 points; 95% CI = 0.14-2.32; P = .028; odds of not valuing life extension: OR = 2.3; 95% CI = 1.3-3.9; P = .004). Depression and anxiety were associated with greater ACP engagement and not valuing life extension. Although the direction of association between ACP engagement and values with anxiety and depression cannot be determined in this cross-sectional study, these conditions may influence ACP preferences. Future studies should assess whether changes in anxiety or depression affect ACP preferences over time.

Implementing advance care planning: A qualitative exploration of nurses' perceived benefits and challenges.

To explore nurses' perspectives on implementing advance care planning (ACP) in an acute setting. Advance care planning can assist patients to achieve peace of mind and a sense of control in decision-making. Nurses are well-positioned to integrate ACP into practice. A descriptive, qualitative study using face-to-face semi-structured interviews was conducted among 16 nurses. A theoretical sampling strategy was used to inform data collection. Data were analysed using a thematic approach. Three major themes were found from nurses' narratives of implementing ACP: value of ACP, communicating ACP and barriers to advocating ACP. Implementing ACP will require a multi-pronged approach, which includes specific training and changes in hospital policies. Findings from this study will enable hospital administrators to make informed decisions in preparing training programmes for ACP from nurses' perspectives. Advance care planning provides a clear direction for health care professionals in meeting patients' desired outcomes. However, a lack of understanding and acceptance among the public, as well as systematic clinical routine supporting nurses' roles and responsibilities in ACP, was recognized.

The Impact of Prior Advance Care Planning Documentation on End-of-Life Care Provision in Long-Term Care.

BackgroundThe impact of prior advance care planning (ACP) documentation on substitute decision-makers’ (SDMs) knowledge of values for end-of-life (EOL) care, and its correlation with SDM satisfaction with EOL care provision, have not been assessed in long-term care (LTC).MethodsA cross-sectional survey of 2,595 SDMs from 27 LTC homes assessed: 1) knowledge of pre-existing ACP documentation and values for EOL care, and 2) the importance and satisfaction of EOL care provision in LTC. Knowledge of values for EOL care was compared to administrative documentation. Importance and satisfaction were plotted on a performance-importance grid. Multiple linear regression assessed whether knowledge of pre-existing ACP documentation correlated with satisfaction.ResultsThe response rate was 25% (658/2,595); 69% of LTC residents had pre-existing ACP documentation. Discordance was noted between SDMs’ knowledge of values for EOL care and administrative documentation. Pre-existing knowledge of ACP documentation was not correlated with EOL care provision satisfaction. Priority areas for increasing satisfaction include illness management, SDM communication, and relationships with LTC clinicians.ConclusionsThe discordance between SDMs’ knowledge of values for EOL care and formal documentation needs to be addressed. Although pre-existing ACP documentation does not impact satisfaction, EOL care provision could be improved by targeting illness management, SDM communication, and relationships with LTC clinicians.

A mixed methods analysis of patients' advance care planning values in outpatient oncology: Person-Centered Oncologic Care and Choices (P-COCC).

Person-Centered Oncologic Care and Choices (P-COCC) combines an advance care planning (ACP) value-focused patient interview with a care goal video decision aid. Our randomized study showed that P-COCC was acceptable but increased participant distress, compared with video-alone and usual care study arms. This mixed methods approach explores the ACP values in the P-COCC arm and their relationship to the distress phenomenon. Qualitative thematic analysis of the 46 audio-recorded P-COCC interview transcripts with advanced gastrointestinal cancer patients was performed by multiple reviewers. Quantitative (Likert scale) changes in ACP values were compared across study arms. ACP themes and value change were analyzed in participants with increased distress. Transcript analysis resulted in thematic saturation and identified eight distinct themes on ACP values relating to end-of-life wishes, communication needs, and psychosocial supports. Of 98 participants (33 P-COCC, 43 videos, 22 usual care) who completed the change in value measure, there was no difference detected with P-COCC compared with either video (p = 0.052) or usual care (p = 0.105) arms alone, but P-COCC led to a frequency distribution of more change in personal values compared with the other study arms combined (p = 0.043). Among the subset of P-COCC participants with increased distress, there was no statistical relationship with change in values. The ACP paradigm P-COCC both informs and supports patients in individualized, value-based decision-making. Distress is not associated with changes in ACP values and may be a necessary, at least transient, byproduct of discussing sensitive but pertinent topics about end-of-life medical care.

Toward Hospital Implementation of Advance Care Planning: Should Hospital Professionals Be Involved?

In Belgium, Advance Care Planning (ACP) is not well implemented in hospital practice. One of the premises for successful implementation is involving the adopters in the implementation process. In hospital, important adopters of ACP are physicians, nurses, social workers, and psychologists. First, this study wants to understand what the characteristics are of ACP in hospital, according to professionals. Second, this study aims to give an insight in the experienced value of ACP. Third, the experienced barriers to have ACP conversations are explored. Twenty-four interviews were taken and analyzed with Content Analysis based on Grounded Theory. Three independent external auditors surveilled the analysis. ACP in hospital exists by the grace of the initiative of the actors involved in the case. Professionals perceive fields of tension between one another; barriers to ACP communication. ACP is mainly considered valuable because it is a process that creates time for exploration and reflection.

Palliative care and advance care planning for pancreas and other cancers.

The principles of palliative care are fundamental to support and treat the physical, mental, and psychosocial health of patients living with pancreatic cancer. In addition to its proven advantages to help manage disease-related symptoms, improve accurate illness understanding, and enhance the quality of life and survival outcomes for patients with advanced disease, the inclusion of palliative care principles (whether by a specialist or by the primary oncology team) with standard oncologic care strengthens timely and quality advance care planning (ACP). The primary objective of this review article is to underscore the significant value of palliative care integration and ACP in oncology, including but not limited to care at the end of life, with a particular focus on its relevance to patients with advanced pancreatic cancer.

Experiences and Perspectives on Advance Care Planning among Individuals Living with Serious Physical Disabilities.

Despite frequent encounters with the healthcare system and high risk for secondary conditions, it is unclear how frequently individuals living with serious physical disabilities document advance directives (AD) or engage in advance care planning (ACP). Their perspectives on these topics are largely unknown. We aimed to characterize the perspectives of individuals with serious physical disabilities receiving care from two different healthcare delivery settings on the value of AD and ACP. Key informant interviews were conducted, audiorecorded, transcribed, and analyzed using thematic analysis and constant comparative analysis. Twenty-five adults with serious physical disabilities were interviewed. Five organizing themes emerged as follows: (A) AD is a right versus responsibility, (B) past medical experiences influence ACP engagement, (C) ACP requires relationship-centered decision support, (D) concerns for care after death, and (E) suggestions for improving ACP experiences. Participants wished to engage in a relationship-centered approach to ACP, yet voiced hesitation due to experiences of significant medical bias and mistreatment, typically surrounding judgments of their quality of life. Better health professional training in ACP and heightened awareness of the unique ACP considerations pertaining to people with disabilities are recommended.

Advance Care Planning in palliative care: A qualitative investigation into the perspective of Paediatric Intensive Care Unit staff

Background: The majority of children and young people who die in the United Kingdom have pre-existing life-limiting illness. Currently, most such deaths occur in hospital, most frequently within the intensive care environment. Aim: To explore the experiences of senior medical and nursing staff regarding the challenges associated with Advance Care Planning in relation to children and young people with life-limiting illnesses in the Paediatric Intensive Care Unit environment and opportunities for improvement. Design: Qualitative one-to-one, semi-structured interviews were conducted with Paediatric Intensive Care Unit consultants and senior nurses, to gain rich, contextual data. Thematic content analysis was carried out. Setting/participants: UK tertiary referral centre Paediatric Intensive Care Unit. Eight Paediatric Intensive Care Unit consultants and six senior nurses participated. Findings: Four main themes emerged: recognition of an illness as ‘life-limiting’; Advance Care Planning as a multi-disciplinary, structured process; the value of Advance Care Planning and adverse consequences of inadequate Advance Care Planning. Potential benefits of Advance Care Planning include providing the opportunity to make decisions regarding end-of-life care in a timely fashion and in partnership with patients, where possible, and their families. Barriers to the process include the recognition of the life-limiting nature of an illness and gaining consensus of medical opinion. Organisational improvements towards earlier recognition of life-limiting illness and subsequent Advance Care Planning were recommended, including education and training, as well as the need for wider societal debate. Conclusions: Advance Care Planning for children and young people with life-limiting conditions has the potential to improve care for patients and their families, providing the opportunity to make decisions based on clear information at an appropriate time, and avoid potentially harmful intensive clinical interventions at the end of life.

Patient-centered conversations: Advance care planning values in the adult oncology population.

147 Background: Over the past 2 years a structured advance care planning program (ACP) has been created, piloted and is evaluated monthly at 10 Texas Oncology practices. This program is a systematic process for assessing patient values, is physician supported and is delivered by advanced practice providers at each site. Patient values and quality of life are at the center of the conversations, enhancing patient-centered care and communication with their oncology providers. Targeted patient populations include metastatic lung, pancreatic and colon cancers. Methods: Over the past 14 months, 332 patients engaged in ACP in ten sites. Descriptive statistics for each site were calculated and examined to explore 1) ACP counseling sessions, 2) number of Patient Values questionnaires completed, 3) frequency of code status documentation in the health record, and 4) hospice enrollment for both the targeted and all metastatic populations. Results: A three month review revealed the ACP work within all metastatic populations at the ten sites. Targeted population totals showed continued increase in the percentages of patient ACP engagement at each site. For the practice as a whole, and the targeted population, 9-23% of patients have received an ACP counseling visit. There have been 149 completed Patient Values questionnaires. In the electronic health record, there are 2,233 (24%) patients who have a documented code status. A range of hospice enrollment from 8-28% in the targeted populations has continued to improve hospice length of stay. Conclusions: The patient is invited to explore their treatment options, their personal values and the completion of the advance directive documents. Truthful conversations are critical between patient and provider in order to create a meaningful treatment plan, and to allow the patient to gain understanding about their options. Early palliative care referrals are integrated into each session for symptom management through local partnerships with palliative care physicians. Education regarding life-sustaining interventions help the patient determine their choices for medical care. Having ACP counseling is important at any stage of health and particularly within life-limiting disease.

Advance Care Planning in Patients With Chronic Kidney Disease

Poor communication and failure to establish goals of care result in unnecessary admissions to hospital, invasive procedures, suffering, and prolongation of the dying process for many CKD patients. Comprehensive CKD care requires systematic integration of advance care planning (ACP). This report describes an approach to ACP for patients with CKD, discusses essential aspects of how to facilitate these conversations, and briefly reviews the empirical evidence supporting the value of ACP.