Table 2.

Best Practice Exemplars of Programs that Support Advance Care Planning.

Respecting Choices®	Serious Illness Care Program (SICP)
Background: • Started in La Crosse, Wisconsin in 1991 as a community-wide initiative • Work of Respecting Choices® took more than 15 years of engaging entire communities collaborating with all hospitals in respective regions Components of Program: • First Steps® (FS): For any healthy adult >18yo who may have chronic illness but has no advance care plan. Goals include motivate patient planning, assist in choosing qualified healthcare agent/decision-maker, provide guidance for goals of care in event of permanent/severe, neurologic injury, complete basic documentation. • Next Steps® (NS): For patients with advancement of chronic illness (e.g., clinical triggers occur, frequent hospitalizations or clinical encounters, decline in function). • Advanced Steps® (AS): Offered as component of quality end-of-life care for frail elders and patients for whom death in following 12 months would not be unexpected. AS focused on goals of care for “timely, proactive, and specific end-of-life decisions”, ideally converted into medical orders that can be followed throughout care continuum (e.g., POLST). Outcomes: • Demonstrated successful community-wide implementation with more than 90% of people dying in that geographic region with a written advance directive, 99% of which were available in patients’ medical records at the time of death, and delivery of treatment that was consistent in the advance care plan¹⁰² • A system-wide implementation of Respecting Choices® in a large healthcare organization demonstrated the limited but meaningful positive impact of ACP in the context of the COVID-19 pandemic 6 years post-implementation, suggesting the possibility of practice culture change to integrate ACP in routine practice¹⁰³ • Respecting Choices®, or derivative models, are adopted by healthcare organizations nationally and internationally Implications: • Outcomes demonstrated by the original work of Respecting Choices® have not been replicated in subsequent studies. • Implementation in one healthcare system without engagement and buy-in from broader organizations or communities may not suffice to change culture and cement ACP into practice • Materials not free for equitable access and dissemination	Background: • Began as a communication training for outpatient discussion of GOC with patients • Has evolved into a program to help build healthcare systems that facilitate earlier, more frequent, and better GOC conversations with patients • Focuses on patients’ goals and values rather than making decisions about future end-of-life care or completing documents; targets patients who are currently living with serious illness, not healthy individuals • Includes communication training for clinicians using the Serious Illness Conversation Guide and strategies to make Serious Illness Conversations (SICs) part of routine practice Components of SIC Guide: • Setup (e.g., asking patient permission to discuss advance planning in context of illness • Assess (e.g., patient understanding, how much information patients want to know about illness in future) • Share prognosis (e.g., in terms of uncertainty, time, or function) • Explore (e.g., goals, fears and worries, strengths, critical abilities, willingness to endure for time gain, loved ones’ knowledge of priorities/wishes) • Close (e.g., reviewing and reflecting conversation, clinician recommendation, partnership statements) Outcomes: • SICP demonstrated educational effectiveness in improving clinicians’ confidence in, satisfaction with, and frequency of engaging patients in ACP conversations^104–107 • SICP studies have also demonstrated decreased anxiety and depression in oncology patients but no significant differences in patient peacefulness or the receipt of goal-concordant care¹⁰⁴ • SICP is adopted in various specialty areas beyond oncology as well as primary care settings nationally and internationally¹⁰⁸ Implications: • Materials free for equitable access and dissemination • Data on successful implementation of SICP in practice and impact on patient/system outcomes are limited

Respecting Choices®

Serious Illness Care Program (SICP)

Background:
• Started in La Crosse, Wisconsin in 1991 as a community-wide initiative
• Work of Respecting Choices® took more than 15 years of engaging entire communities collaborating with all hospitals in respective regions
Components of Program:
• First Steps® (FS): For any healthy adult >18yo who may have chronic illness but has no advance care plan. Goals include motivate patient planning, assist in choosing qualified healthcare agent/decision-maker, provide guidance for goals of care in event of permanent/severe, neurologic injury, complete basic documentation.
• Next Steps® (NS): For patients with advancement of chronic illness (e.g., clinical triggers occur, frequent hospitalizations or clinical encounters, decline in function).
• Advanced Steps® (AS): Offered as component of quality end-of-life care for frail elders and patients for whom death in following 12 months would not be unexpected. AS focused on goals of care for “timely, proactive, and specific end-of-life decisions”, ideally converted into medical orders that can be followed throughout care continuum (e.g., POLST).
Outcomes:
• Demonstrated successful community-wide implementation with more than 90% of people dying in that geographic region with a written advance directive, 99% of which were available in patients’ medical records at the time of death, and delivery of treatment that was consistent in the advance care plan¹⁰²
• A system-wide implementation of Respecting Choices® in a large healthcare organization demonstrated the limited but meaningful positive impact of ACP in the context of the COVID-19 pandemic 6 years post-implementation, suggesting the possibility of practice culture change to integrate ACP in routine practice¹⁰³
• Respecting Choices®, or derivative models, are adopted by healthcare organizations nationally and internationally
Implications:
• Outcomes demonstrated by the original work of Respecting Choices® have not been replicated in subsequent studies.
• Implementation in one healthcare system without engagement and buy-in from broader organizations or communities may not suffice to change culture and cement ACP into practice
• Materials not free for equitable access and dissemination

Background:
• Began as a communication training for outpatient discussion of GOC with patients
• Has evolved into a program to help build healthcare systems that facilitate earlier, more frequent, and better GOC conversations with patients
• Focuses on patients’ goals and values rather than making decisions about future end-of-life care or completing documents; targets patients who are currently living with serious illness, not healthy individuals
• Includes communication training for clinicians using the Serious Illness
Conversation Guide and strategies to make Serious Illness Conversations (SICs) part of routine practice
Components of SIC Guide:
• Setup (e.g., asking patient permission to discuss advance planning in context of illness
• Assess (e.g., patient understanding, how much information patients want to know about illness in future)
• Share prognosis (e.g., in terms of uncertainty, time, or function)
• Explore (e.g., goals, fears and worries, strengths, critical abilities, willingness to endure for time gain, loved ones’ knowledge of priorities/wishes)
• Close (e.g., reviewing and reflecting conversation, clinician recommendation, partnership statements)
Outcomes:
• SICP demonstrated educational effectiveness in improving clinicians’ confidence in, satisfaction with, and frequency of engaging patients in ACP conversations^104–107
• SICP studies have also demonstrated decreased anxiety and depression in oncology patients but no significant differences in patient peacefulness or the receipt of goal-concordant care¹⁰⁴
• SICP is adopted in various specialty areas beyond oncology as well as primary care settings nationally and internationally¹⁰⁸
Implications:
• Materials free for equitable access and dissemination
• Data on successful implementation of SICP in practice and impact on patient/system outcomes are limited