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A Tried and Tested Strategy for Advance Care Planning


The use of advance care planning (ACP) to make future decisions can increase compliance with patients’ end-of-life wishes, decrease inappropriate life-sustaining treatment, and reduce stress, anxiety and depression. Despite this, only a fraction of people engage in advance care planning, partly because of the difficulty many providers face when approaching these conversations with older people and their families.

“Advance care planning improves a person’s end-of-life care and helps to ensure the treatment people receive is the treatment they want,” noted Lisa Vitucci, Prospero’s National Social Work Director.

Prospero’s care teams prioritize completing advance care directives with patients, and we’ve learned the importance of what we call “The Three T’s of ACP”: Time, Team and Trust.

Social worker discussing advance care planning with aging Prospero Health patient
Albert, a Prospero patient (left), and Heather, a Prospero social worker (right), enjoy their conversations during Albert’s appointments. 

Time: Don’t Rush Advance Care Decisions

First, care teams must offer the time a patient needs to make critical decisions. Delicate conversations with patients and their families are not typically resolved within the window of a 30-minute appointment. The only way to ensure everyone is comfortable is to provide the necessary information, time, and space.

“Advance Directive conversations are best held on several occasions over a period of time,” offers Prospero’s Social Work Clinical Educator Heather DiYenno, who is also a Licensed Clinical Social Worker, “and it’s important to cover an individual’s values, fears, and future healthcare goals and preferences.”

“Advance Directive conversations are best held on several occasions over a period of time, and it’s important to cover an individual’s values, fears, and future healthcare goals and preferences.”

Heather DiYenno

“We work together as a team to help our patients understand what it all really means,” adds Prospero Social Worker Karen Possessky, “It does take time, you have to have the conversation in doses to really get it. Often people get to the hospital or are being rolled into surgery and are told, ‘Here’s a form if you haven’t already filled out your advance directives.’ That’s crazy, because often those patients haven’t explored what their beliefs and values are, and they don’t even understand what artificial nutrition and hydration is. Patients need the time to collect all of the information before they can deliberate, decide and discern what their directives are.”

Aging father and son reviewing advance care plan and healthcare directives together
Include family caregivers in advance care conversations, in addition to your patient’s specialists and other providers.

Team: Involving The Patient’s Support Team in Directive Planning

It’s also imperative to consider the entirety of a patient’s team. People with chronic illnesses typically are in the care of a number of different doctors, in addition to their family caretakers and/or home health aides. It’s crucial that all perspectives, diagnoses and provider recommendations are taken into account, and that everyone is kept informed and updated of the patient’s wishes and directives. 

“You can’t deny that caregivers are intertwined in the process, these decisions affect them as well,” explains Possessky. “I can’t tell you how many elderly people’s wishes are suppressed by a well-meaning family member, and it takes time and communication to get to the root of those conflicts.”

Trust: Establish Trust & Facilitate Aging Discussions

The final cornerstone of successful ACP is earning the trust of patients and their families. Research shows that patients are less open to advance care planning if they lack trust or have negative thoughts regarding a provider’s interest in their well-being. Interestingly, the same study showed that engaging in advance care planning actually appeared to increase patient trust. 

“Our role is to facilitate these difficult, emotional conversations that are core to who we are and that need to happen in order for a person to maintain their human self worth and dignity,” says Possessky. “It’s the preemptive work that needs to be done in order to hopefully promote a peaceful end of life that is lovely and beautiful. It will always be sad, but it doesn’t have to be a struggle.”


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