Introduce the topic: “Can we talk about where things are with your health, and where things might be going?”

Seek permission: “Is this okay?”

Inform: Explain what ACP is and why it is important. Describe the process. Tell the patient that his or her decisions can be revised as health status or life situations change

Follow up, if appropriate: After introducing the patient to the topic of ACP, consider having the patient return for a dedicated appointment to continue the rest of the process

“How much do you (or your family) know about your illness?”

“What information would you like from me?”

“What are the most important things you want to do in life?”

“What are some abilities in life that you cannot do without?”

“What are your biggest fears and worries about your health? Or about life in general?”

“If you get sicker, what kinds of health care services are you willing to endure to gain more time?”

Patient should decide on who will be the SDM (“If you are unable to speak for yourself about medical decisions, who do you want to speak for you?”)

You need to decide which patient-centred principles are based on, and comply with, the values that the patient has identified as being most important to his or her life

This component of the ACP discussion might require multiple discussions if there is no medical indication for an urgent decision

Document the designation of the SDM. The patient should ensure that the SDM is aware of his or her role and is informed of the patient’s priorities and wishes

Document any principles-of-care decisions that have been made

Ensure that documentation complies with relevant provincial, territorial, or regional regulations regarding the documentation of designated SDMs and decisions specifying principles of care