Background Advance care planning (ACP) structures complex situations and offers pragmatic support. Early integration of Palliative Care into care pathways of any chronic life-limiting disease necessitates the early definition of a patient/family driven care plan.

Aim The authors developed a person-centred, needs-driven ACP framework helping patients to define their preferences in complex situations and strengthen their self-effectiveness. It should structure an effective multiprofessional team approach with active patient/family participation. The framework needed to be applicable in all health care settings.

Methods To develop the SENS-framework existing structured approaches from the literature were critically evaluated and clinically tested. According to a literature-based structured list common topics where developed by analysing more than 500 documentations of ACP conversations. The resulting SENS-framework was then pilot-tested in various settings. Qualitative interviews were collected.

Results As a starting point the authors developed clusters with common topics. Specifically the acronym “SENS” covers: Symptoms a patient faces; End-of-life decisions; organising the Network around the patient; and the needed Support for the family to endure the situation. Professionals and patients/families reported clear benefit from SENS-structured care plans. A SENS-based prompt sheet for patients facilitates the ACP conversations.

Discussion/conclusion SENS has been adopted quickly by clinicians as well as by patients and family as a pragmatic tool to structure assessment, interprofessional planning, conversation and documentation in advanced illness. SENS seems to stimulate patient – professional partnership and may reflect better personal needs compared to pure care based on medical diagnosis. An RCT is under way to test its impact on quality of care in three tertiary hospitals in Switzerland.