Integrating ACP Conversations into Practice
Adaptations of the ACP Conversation process may be required for each clinical environment. The following is a suggested process for clinical implementation that can be broken down over multiple patient interactions.
ACP = Advance Care Planning
SDM = Substitue Decision Maker
POA = Power of Attorney (in this case the person would be appointing an Attorney for Personal Care)
Start Here
Is your patient capable of participating in Advance Care Planning (ACP) Conversations?
Is your patient ready to participate in ACP conversations?
Give Resources on ACP and SDM
SDM discussion: confirm SDM(s), or give info about POA documents.
Document SDM(s) and ask for a copy of POA document if applicable.
Complete.
Provide resources on personal values clarifications and talking to their SDM(s) about ACP.
*Bring SDM(s) to next appointment.
ACP Conversations
Wishes, values and beliefs are communicated to SDM(s).
Complete.
Ready to discuss the role of a SDM(s) and who their default SDM(s) would be?
Provide info on SDM(s) if person accepts and revisit at next appointment.
Complete.
Is your patient ready to participate in ACP conversations?
Revisit and provide counseling appropriate to readiness.
Complete.
Is your patient capable of appointing an Attorney for Personal Care?
SDM has Goals of Care and Treatment discussions when needed.
Document SDM(s) and ask for a copy of POA document if applicable.
Complete.