Table 1

Approach of ACP conversation as outlined in the ACP+conversation guide

The ACP+conversation tool
Add sentences that are convenient for you
Sections A and BSections C and DSections E, F, G, H and ISummarise, document and follow-up
Section A: Ideas about a good life
(broadly asking about values)
‘What is important to you?’
‘Which things make you feel joy?’
‘What are you proud of?’
‘What makes life worth living?’
‘Do you think you have had a good life?’
‘What do I need to know about you to give you the best possible care?’
‘How could we improve your care?’
‘Which things give you strength?’
‘Do you have cultural, religious or spiritual beliefs? Would you like to talk about this with someone?’
‘At which point do you consider life not to be worth living anymore?’
‘What would you like your family, children and grandchildren to remember about you?’
‘What would you like to finish in your life?’
‘To which things would you still like to dedicate some time and energy?’
‘Is there something you are strongly looking forward to?’
‘Could you summarise for me what the doctors told you about your current health status?’
‘What do you expect to happen to you?’
‘What makes you happy? What is essential for your quality of life?’
‘Is there any business that you would like to finish?’
Section B: Preferences for current care and treatment
‘How do you consider your current quality of life?’
‘Do you currently have a good life?’
‘How do you cope with your dementia/getting older?’
‘What is the hardest part for you about living with dementia?’
‘Do you find it hard to get older?’
‘What does ageing mean to you?’
Section C: Preferences for future care and care goals
Ideas and worries about the future and the end of life
‘When considering the future, what do you hope for/ are you worried about?’
‘When considering your illness, what would be the best or worst thing that could happen to you?’
‘Are you afraid to die?’
‘Did you ever witness someone getting very ill, becoming dependent, or dying?’
‘Did you ever witness someone else’s death, good or bad? How did you experience this?’
‘Is there something you are afraid of? What would you rather avoid?’
The importance of ACP
‘Have you ever considered the medical care you would like to receive when you are too ill to decide on this? That is the goal of ACP, to guarantee you that you are cared for according to your wishes, even when you cannot convey these anymore.’
Common goals of care
‘Your health status could change in the future. Sometimes people can adjust or get used to this new situation, but not always. In the past you have told me that (eg, not being hospitalised…) was important to you. Is this still the case?’
‘Would you like to consider your future health?’
‘Is it important to you to make your own decisions? If so, what are the things you would like to decide about?’
‘What is more important to you: suffering as little as possible/focusing on quality of life or living as long as possible?’
Section D: Appointing a legal representative
‘In case you would become so ill, you could no longer make decision about you care for yourself, is there someone you trust enough to make these decisions for you?’
‘Would you like to appoint a legal representative?’
Section E: Documenting end-of-life wishes
Advance directives
‘There are several ways to document your wishes. Some people think it is useful to compose an Advance Directive. You don’t have to do this if you don’t want to, and you should certainly not rush into this. Shall we discuss all the options together?’
‘Have you ever heard about palliative care? What is your experience with this?’
‘Would you still like to go to the hospital if you are in a critical state?’
‘Do you have an Advance Directive? Would you like to compose an Advance Directive?’
In case of questions posed by resident or family about euthanasia*:
‘What does euthanasia mean to you?’
Preference with regard to resuscitation
‘There is a chance that you suddenly experience cardiac arrest, if this happens we can resuscitate you. Are you familiar with this? Have you ever thought about if you would want this?’
‘Would you like to be resuscitated?’
Section F: Place of care/death
‘Where would you like to be cared for at the end of life?’
Section G: Other preferences
‘Are there other preferences you would like to take us into account?’
Section H: Preferences with regard to dying
‘Are there specific (religious) wishes that we should consider?’
‘Would you like to make funeral arrangements?’
Section I: Revising preferences and wishes
‘Which circumstances would be a reason for you to revise your wishes and preferences about the care?’’
Summarise the conversation
‘So today you told me about… Is that correct?’
‘Do I understand correctly that today we decide on the following…?’
Document wishes and preferences
  • ACP+Document

  • ACP+Summary

  • Advance directives

  • Care codes (ABC, DNR)

  • Check if all documents correspond with each other

Planning a follow-up conversation (if wanted)
‘A while ago we spoke about… You told me about… Is this still applicable?’
‘A year ago, we spoke about … I was just wondering how you feel about this now. Would that be alright for you to discuss this?’
Communication to other involved healthcare professionals
  • Notes/copy in the (digital) nursing home file of the resident

  • Mention during the (monthly) multidisciplinary meetings to inform all healthcare staff

  • Inform the general practitioner

  • *Euthanasia is a legal option in Flanders for people with decision-making capacity. This particular question should be considered in the light of this legal framework.

  • ACP, advance care planning.