Date of Publication


Project Team

Margaret Aitken DNP, APRN


Background: Advance care planning (ACP) encourages patients to consider their healthcare goals and communicate them with family and healthcare providers. The ACP process promotes patient-centered care and decision-making in accordance with the patient’s goals and wishes. While about 50% of Americans adults have completed advance directives (AD), as few as 10% have had ACP discussions with their primary care provider (PCP).

Purpose: The purpose of this project was to increase the number of ACP discussions initiated during a routine office visit with a primary care by implementing a patient-centered intervention.

Methods: Patients meeting specific criteria were identified using a report created in the EHR. Eligible patients were mailed a letter describing the benefits of ACP. 8 of these patients also received a blank AD document. Two PDSA cycles were completing during the project and were used to evaluate and modify interventions.

Results: 68 unique patient charts were reviewed. Of these, 35 were eligible participants. During the project, 3 participants provided a previously completed AD, one participant completed an AD, and 3 participants were referred for future ACP discussion, accounting for 20% of eligible participants.

Discussion: Preparing patients in advance of a scheduled appointment to consider their healthcare goals and preferences can increase rates of ACP discussion. Patients should be encouraged to provide a copy of their pre-existing AD, if they have one. A process for follow up may improve ACP discussion rates.

Document Type


Available for download on Saturday, April 18, 2026

Included in

Nursing Commons