Introduction: Since regional advance care planning (ACP) programs have demonstrated effects that to many seemed impossible until recently, widespread implementation into regular care is a matter of time. But where are we heading for, and how can we get there?
Methods: Review of the literature and analysis of experiences with a German ACP program.
Results: ACP is a powerful concept to strengthen patients' autonomous choices in situations of severe illness. As ACP requires a change in decision making culture, it cannot be decreed – it needs to be implemented in an evolutionary regional process, involving the community and relevant health care institutions. Most countries will need to see thriving ACP pilots before nation-wide programs can be launched. However, barriers and pitfalls have to be considered. Realizing patient autonomy is not embraced by all, some worry that ACP will pave the way for active euthanasia, and many fear a hidden health-economic rationale. In order for an ACP program to become a sustained success, the resulting care plans must prove to be both relevant (i.e., making a difference) and valid (i.e., congruent with the person's true intention). Relevance and validity of advance care plans, however, are primarily a function of skillful facilitation. Besides transparency of economic incentives, research and implementation policies should concentrate on facilitator qualification, standards of the facilitation process, and assessments warranting that advance care plans are relevant and valid.
Conclusion: In the long run, ACP programs will stand or fall with the proven quality of the implemented professional facilitation process.
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