Table 2. Strategies to Systemize ACP and End-of-Life Communication.

Intervention	Description
Train clinicians	• Communication skills training
Identify patients at risk	• Patients with progressive disease
	• Patients with no next of kin or who live alone
Trigger communication in the outpatient setting before a crisis	• Develop as criteria with appropriate timing
	» Disease progression
	» Treatment change
	» Toxicity from treatment
	» Increased symptom burden
	• Schedule separate visit
Educate patients and families	• Initiate discussion before decisions are required
	• Provide appropriate information about prognosis based on information preferences
	• Focus on goals and values about care
	• Encourage discussion of non-medical goals
	• Encourage families and patients to reflect on and clarify their wishes through discussion on an ongoing basis
Use checklist conversation guide	• Understanding: What is your understanding about your illness?
	• Information preferences: How much information would you like from me about your illness?
	• Prognosis: Share prognosis tailored to information preferences
	• Goals: What are your most important goals if your health situation worsens?
	• Fears/worries: What are your biggest fears and worries about the future with your health?
	• Function: What abilities are so critical to your life that you can’t imagine living without them?
	• Trade-offs: If you become sicker, how much are you willing to go through for the possibility of gaining more time?
	• Family: How much does your family know about your priorities and wishes?
Improve communication of critical information in the EMR	• Designate a site in EMR for a “single source of truth” for recording and retrieving of patients’ values, goals and preferences of care as well as other key information
	• Health-care proxy
	• Medical order for life-sustaining treatments
	• Code status
Measure and report performance	• Develop appropriate performance standards

Note. EMR = electronic medical record. Information from Bernacki & Block (2014).