Table 1.

Introduce, Discuss, Decide, and Document framework: Use the following framework for ACP discussions.

IntroduceBegin ACP discussions by ...
  • 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

DiscussAssess a patient’s understanding
  • “How much do you (or your family) know about your illness?”

  • “What information would you like from me?”

Determine a patient’s goals
  • “What are the most important things you want to do in life?”

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

Ask a patient about his or her fears
  • “What are your biggest fears and worries about your health? Or about life in general?”

Explore a patient’s trade-offs
  • “If you get sicker, what kinds of health care services are you willing to endure to gain more time?”

DecideMake decisions
  • 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

DocumentInclude documentation of certain factors
  • 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

  • ACP—advance care planning, SDM—substitute decision maker. Dialogue prompts adapted from Ariadne Labs.9