Table 1.

Description of advance care planning (ACP) intervention

Session	Foundation	Goals	Process
1	Disease-Specific Advance Care Planning (DS ACP) Respecting Choices Interview® [24]	To facilitate conversations and shared decision-making between the PLWH and surrogate about ACP, providing an opportunity to express fears, values, spiritual and other beliefs, and goals with regard to death and dying To prepare the surrogate to be able to fully represent the PLWH’s wishes	Stage 1: Assesses the PLWH’s understanding of current medical condition, prognosis, complications Stage 2: Explores PLWH’s philosophy regarding EOL decision-making and their understanding of the facts Stage 3: Reviews rationale for future medical decisions the PLWH would want the surrogate to understand/act on Stage 4: Uses the Statement of Treatment Preferences (SoTP) to describe clinical situations common to AIDS and likely comorbidities and related treatment choices Stage 5: Summarizes the discussion or need for future discussions as situations/preferences change Gaps in information are identified and referrals are made Session is videotaped for fidelity purposes
2	The Five Wishes© [25] is a legal document that helps a person express how they want to be treated if they are seriously ill and unable to speak for themselves. Unique among living will and health agent forms, it addresses all of a person’s needs (medical, personal, emotional, spiritual)	Identify person the patient wants to make health care decisions for him/her The kind of medical treatment the patient wants How comfortable the patient wants to be How the patient wants people to treat him/her What the patient wants loved ones to know	Processes, such as labeling feelings and concerns, as well as finding solutions to any identified problem, are facilitated. Appropriate referrals are made to help resolve disagreements over decision-making (e.g. a hospital ethicist or their doctor) or spiritual issues (e.g. a hospital chaplain or their clergy) Both sessions may include other family members or loved ones