Table 3.

Recommendations for a Balanced Approach to Advance Care Planning.

Domain	Recommendations
Serious Illness Clinical Practice: Holistic ACP for Patients and their Social Support Structures	⦁ Approach ACP as an opportunity to build rapport, foster trust, promote relationship-based care, and elicit patient and family values, goals, preferences, and needs beyond documentation requirements ⦁ Foster intentional ACP discussions throughout the trajectory of serious illness care, with particular attention to moments of prognostic or psychosocial transitions, greater severity of symptoms, or increased proximity to end-of-life ⦁ Normalize high-quality ACP discussions as a core standard of quality primary care, primary palliative care, and serious illness care, using discussion findings to further explore changing values, etc. ⦁ Actively engage surrogates, caregivers, and other social supports into ACP discussions to promote inclusivity, co-participation, and alleviate stressors that may contribute to decisional conflict ⦁ Advocate for documentation and EHR improvements that assist with ongoing tracking of ACP preferences to ensure an iterative ACP dialogue with care recipients ⦁ Partner with palliative specialists to improve serious illness communication skills ⦁ Include ACP preferences as a part of patient “hand-off” and when collaborating with interprofessional colleagues and/or consulting services
Serious Illness and ACP Research	⦁ Design and implement longitudinal research to evaluate patient/family and clinician experiences with ACP starting at time of serious illness diagnosis to bereavement ⦁ Explore clinician and system barriers, needs, and facilitators to ACP discussions and use implementation science to guide interventions that support clinician confidence during ACP encounters ⦁ Evaluate the feasibility, acceptability, and efficacy of training programs that assist clinicians, patients, surrogates, communities, and lay navigators to develop and hone ACP communication skills ⦁ Advocate for increased ACP research funding to address evidence gaps and promote comprehensive investigation of ACP utility ⦁ Compare ACP with other forms of serious illness communication and generate additional data on the association between ACP and health services at end of life ⦁ Design valid tools to measure clinician and patient/family experiences and perceptions of ACP with particular attention to the high-stakes circumstances inherent to serious illness
Serious Illness and ACP Policy	⦁ Increase fiscal investments in ACP research in a multitude of settings, including acute and critical care, long-term care, community-based and nursing home care, and throughout serious illness care delivery for pediatric and other vulnerable and/or historically excluded populations ⦁ Call for required training to promote primary palliative care and serious illness care skills and communication for all clinicians by integrating and supporting key legislation, such as the Palliative Care and Hospice Education Training Act (PCHETA) ⦁ Revise ACP billing codes to promote robust clinician-patient discussions, clarity on reimbursement, user incentives, and frequency of use ⦁ Support public health education regarding ACP awareness and patient/family empowerment to address ACP preferences with clinicians and care teams, particularly in serious illness ⦁ Invest in the expansion of palliative care specialist services to support timely ACP communication in the serious illness context