If the patient has never heard of ACP or is not interested, the first conversation may focus on explaining ACP, how it may be beneficial and how it can impact future care.
If a patient is accepting of ACP, a pamphlet explaining the elements can be provided.
If the patient is not yet ready to consider discussing ACP, it may still be an opportunity to discuss his or her SDM(s).
Patient does not know about or has considered ACP
Patient may be aware of ACP but not ready to take action
Patient reviews ACP educational materials or discusses the topic of ACP
Patient knows who their SDM(s) is, has discussed wished, values and beliefs with SDM(s) and may request help for further clinical information
Willing to revisit ACP conversation with SDM(s)
Introduce ACP and provide educational material if patient seems open
Indicate questions or concerns about ACP can be addressed in future visits
Ask if they have questions or need further information about ACP as well as their current health circumstances. Offer resources that would assist identifying values or wishes. Talk about the role and importance of SDM.
Engage in discussion regarding ACP educational materials. Discuss automatic SDM(s), Attorney for Personal Care if necessary and alternate in case SDM(s) unwilling or unable to assume duties.
Meet with patient and the SDM(s) to facilitate ACP conversation
Periodically review and discuss ACP particularly with a change in health status or with critical illness or EOL of family member or friend