Table 2.

Opportunities for ACP discussions across stages of illness and health care settings

Recommended ACP Steps	Setting and Timing	Description	Who can Initiatea	Example Questions
Assessing patients’ readiness	At any stage in the illness trajectory and in any setting	Exploring patients’ readiness to discuss ACP	PCP and/or cardiologist with assistance from multidisciplinary team (eg, social workers, nurses, facilitators)	At this clinic/hospital, we ask all patients to plan for their future medical care in case they lose the ability to make their own medical decisions. Can we talk about this today? Is there anyone you would want with you when we talk about this? Have you ever completed an advance directive, such as a living will? Can we review this? If you were to fill one out, have you thought about what you might say?
Addressing patient barriers	At any stage in the illness trajectory and in any setting	Identifying and addressing patients’ concerns related to ACP	PCP and/or cardiologist (with multidisciplinary team)	Are there things that you worry about when you think about planning for future medical care? What makes it difficult to talk about such things with me or your loved ones?
Identifying surrogate decision-makers	At the time of diagnosis or referral to cardiologist	Identifying a trusted person as a surrogate decision-maker to help clinicians apply the patients’ values to specific clinical situations	PCP and/or cardiologist (with multidisciplinary team)	Is there someone you trust to help make medical decisions on your behalf, if you are not able to do so? What have you talked about? or What would you tell this per- son is important about your medical care?
Documenting ACP preferences	After ACP discussions, at any stage in the illness trajectory and in any setting	Documenting preferences in the medical record and/or advance directive (ie, medical power of attorney)	Clinician or trained team member involved in the ACP discussions	Because you have chosen (loved one) to help make decisions on your behalf if you are very sick and unable to talk with me, I recommend that you complete the medical power of attorney form to make it official.
Assess understanding of illness and discuss prognosis	During routine care, including cardiac device placement, procedures, or during hospitalization	Understanding the patients’ understanding and providing disease trajectory education and prognosis	PCP and/or cardiologista	What have your doctors told you about your illness and what to expect? Many people want to know their life expectancy or how long they may have to live. For each person we never know for sure, but based on your heart disease we do know general estimates. Knowing this information helps some people make medical decisions. Is this something you would want to know?
Asking about values related to quality of life	During routine care, including cardiac device placement or procedures or during hospitalization	Exploring the individual’s values and priorities in life and discussing what constitutes an acceptable quality of life	PCP and/or cardiologist,a hospitalist, palliative care (with multidisciplinary team)	What are you looking most forward to over the next few years. What gives your life meaning? Do you know other people with heart disease? How have their experiences been? Are there parts of their experiences that help you decide what type of treatment you would or would not want for yourself? I know you were just hospitalized with heart failure. What was that like for you and your family? If you were in this situation again, what would you hope for? What would you be most worried about? Did this situation change the way you may be thinking about your care or ways of living that would or would not be acceptable to you?
Documenting ACP preferences	After ACP discussions, at any stage in the illness trajectory and in any setting	Documenting preferences in the medical record and/or advance directive (ie, living will)	Clinician or trained team member involved in the ACP discussions	Because you have told me what would be important to you about certain life-sustaining medical interventions if you have certain serious medical conditions, I recommend that you complete a living will to help your loved ones and health care providers known your preferences.
Translating patients’ values into specific treatment plans	During hospital, ICU, or nursing home admission	Translating values into current medical care documents (ie, POLST form, CPR directive)	PCP, cardiologist,a intensivist, palliative care team, nursing home attending	Based on what you have told me about what is important to you in life, how you want to live, and the health states that are/are not acceptable to you, and based on the risks and benefits of this treatment, I would recommend (option).
Communicating with health care providers from other settings	During routine care and care transitions, including use of postacute care (ie, skilled nursing facility or home health)	Facilitating verbal and written communication of patients’ preferences, including transfer across settings	PCP, cardiologist, nursing home provider, outpatient palliative care, (with multidisciplinary team)	Based on our conversation today, and the (advance directive we completed/the POLST form I completed), I am going to make a note and place these forms in your medical record. I would like to send a copy to your other providers and your hospital so they know your wishes.

Abbreviations: ICU, intensive care unit; PCP, primary care provider; POLST, Physician Orders for Life-Sustaining Treatment.

^aThe primary or cardiology providers may include physicians, advance practice nurses, physician assistants, and can be assisted by multidisciplinary team members, including trained facilitators who may be nurses, social workers, chaplains, health coaches, or patient navigators.

Data from Refs.^8,10,31