The majority of chronically ill individuals do not participate in advance care planning (ACP) and therefore are denied the opportunity to clarify their values, treatment preferences and goals for end-of-life care. Numerous patient, health care provider and health system barriers to routinely facilitating effective ACP have been identified. Unlike other interventions, there are no consistent standards about when to initiate or how to conduct these discussions. In addition, patients' perspectives of the salient elements of ACP and their preferences regarding how ACP should be facilitated may differ from those of their health care professionals. Recently, however, systems and processes have been evolving to integrate ACP into routine clinical care for patients with advanced diseases, involving substantial behavioural change, health information technology, social marketing and legislation/policy changes.
While data from clinical trials of multidimensional ACP interventions remain limited, preliminary evidence strongly supports the value of ACP in allowing patients to prepare for death, strengthen relationships with loved ones, achieve a sense of control, relieve burdens placed on others and through all this positively enhance hope. ACP has also been shown to strengthen patient-physician relationships, achieve higher congruence between surrogates and patients in their understanding of patients' end-of-life preferences, and attain greater satisfaction with and less conflict about these end-of-life decisions. Data specific to end-of-life care practices are more limited but suggest ACP has positive outcomes such as increased hospice length of stay, less time spent in hospital and more deaths occurring at patients' place of choice.
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