Overview & Summary: Advance Care Planning: Strategies for Nurses

My career as a clinical nurse specialist has included starting a hospice agency in rural Appalachia and an acute care palliative care service in a level-one trauma, academic medical center. During this time, I have seen the importance of eliciting patients’ treatment preferences and care values and unfortunately, the devastating consequences when advance care planning (ACP) has not occurred or has been done poorly. The National Institute on Aging encourages ACP conversations and provides helpful tips and resources. Yet only one-third of all adult citizens in the United States complete an advance medical directive (AMD), for older adults around 50% (Moore et al., 2021; Whitehead et al., 2021).

ACP has been encouraged for decades, and yet it continues to be a challenge for patients, families, and clinicians. There have been, and continue to be, many initiatives to improve ACP including my own endeavors, creation of the Model of Meaningful Conversation in Serious Illness©, with an accompanying measure, Patient Preferences About Serious Illnesses (PASITM). (Whitehead & Carter, 2017; Whitehead et al., 2016). Over the years, the American Nurses Association (ANA) and Hospice Palliative Nurses Association (HPNA) have encouraged ACP. I was selected to chair the Hospice Palliative Nurses Association ACP Workgroup with national experts resulting in a manuscript that summarized best practices and implications surrounding ACP.

We know the benefits of ACP include improved end-of-life care and satisfaction, increased hospice and palliative care use, cost savings due to fewer hospitalizations and aggressive interventions, diminished decisional conflict of surrogate decision-makers, and enhanced primary care experiences (Whitehead et al., 2021). And yet, ACP continues to be challenging with too much uncertainty and lack of guidance about how best to care for our seriously ill and injured patients when they are confronted with gut-wrenching decisions. Furthermore, nurses have cited numerous challenges to facilitating ACP such as a perceived lack of education, training, and/or mentorship as well as a lack of high-quality research to support an evidence-based, nurse-led ACP training model (Whitehead et al., 2021).

The six introductory articles that follow in this OJIN topic address the challenges of facilitating ACP by detailing real and perceived barriers. The articles offer many strategies for nurses to consider as they reflect on their own duty to assist patients and families with this often daunting, but so important, process.

The first article by Parajuli, Jackson and McLennon, “Advance Care Planning: Overview and Resources for Healthcare Professionals, Patients, and Families” walks us through the importance of ACP including benefits, barriers, and resources for nurses, patients and families. The authors describe the need for ACP along with current statistics and discuss the process of ongoing conversations with one’s patients and their families. They provide detailed components for successful ACP and review the 2025 Institute of Medicine’s report, Dying in America. They emphasize the benefits of ACP such as enhanced satisfaction with care for patients, families, and healthcare practitioners. Parajuli and colleagues highlight the barriers including the lack of standardized guidelines and documentation for ACP. They provide a comprehensive list of resources and review the role of nurses in these conversations and documentation. The article concludes with a call to action for nurses especially in palliative and hospice care to advocate for improved ACP.

“Integrating Advance Care Planning into Advanced Practice Registered Nurse Practice: Overcoming Barriers and Enhancing Billing Strategies” by Kates and Frechman is a call to integrate ACP into advanced practice registered nurse (APRN) practice. The authors share the growing chronic disease statistics in the United States. They discuss the Institute for Healthcare Improvement 4 Ms framework, the Affordable Health Care Choices Act in 2009, and Centers for Medicare and Medicaid Services as catalysts for improved ACP by all APRNs (i.e., Nurse Practitioners [NP], Clinical Nurse Specialists [CNS], Certified Nurse‑Midwives [CNM], and Certified Registered Nurse Anesthetists [CRNA]). Kates and Frechman delineate the barriers to ACP and provide potential solutions. They illustrate their proposal with a case study and conclude with recommendations about how to transform ACP across key groups.

Kimpel and Maxwell summarize and synthesize barriers and facilitators to ACP using 4 publications from their own previous qualitative studies in “Barriers and Facilitators to Advance Care Planning for Special Populations: Adults with Low Income in Nashville, Tennessee”. They discuss five emerging themes that include healthcare, health insurance, and health; structural factors; interpersonal factors; religious beliefs; and personal factors. The authors reflect upon the unique role of nurses to address each of the 5 themes. They discuss trauma informed care as an approach for ACP with low socioeconomic status populations and conclude with recommendation about how nurses can improve ACP.

In “Strategies and Tools for Implementing Advance Care Planning Across the Continuum,” Joyner and Sharma present strategies and tools for ACP by examining a fictional case study to illustrate the complexities of healthcare while utilizing the Continuum of Advance Care Planning model. They review numerous ACP tools/instruments that can improve discussions and documentation of patient treatment preferences. These authors conclude the article by emphasizing the importance of teamwork and communication with patients, families, and health professionals.

Medical Aid in Dying (MAID) is the practice where terminally ill patients who are mentally capable adults can voluntarily request prescribed medication to be self-administered in order to end their life in a peaceful manner. In “Medical Aid in Dying the United States: Review, Discussion and Guidance for Nurses,” authors Daly, Fry and Schattinger introduce the readers to MAID, and offer an overview of the history and process of MAID in the United States. They discuss attitudes, ethical principles/codes and position statements from various professional healthcare organizations. The authors conclude with considerations for all nurses whether they work in states with or without legislation that supports MAID.

The article by Miller and Reitz, “Evidence Based Strategies for Nursing Students and Advance Directive (AD) Preparedness” summarizes current research related to nursing students’ knowledge about ADs. The authors discuss evidence-based strategies for nurse educators including experiential learning via simulation, community partnerships, and the impact that nurse faculty have on student experiences with ACP. The authors conclude with a review of End-of-Life Nursing Education Consortium (ELNEC) as a comprehensive strategy to address required palliative care and ACP competencies.

The final article, “End-of-life Conversations and Interventions: Report on Nurses’ Perspectives about Collaboration in a Community-Based Study,” by Holston and Volpin, describes their research regarding The Project Talk Trial between nurses and local organizations in an underserved community. The authors discuss the importance of trust, transparency, respect, consistency, communication, and networking among nurses and communities where they work and live. They review implications that include community collaboration and advocacy. The authors conclude by noting that stakeholders have one shared goal: to improve the healthcare of those who live in underserved communities.

The journal editors invite you to share your response to this OJIN topic addressing the benefits and challenges of Advance Care Planning either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Author

Phyllis Whitehead, PhD, APRN/CNS, ACHPN, PMGT-BC, FNAP, FCNS, FAAN
Email: pbwhitehead@carilionclinic.org
ORCID ID: 0000-0001-9530-1102

Dr. Phyllis Whitehead is a clinical ethicist and clinical nurse specialist with the Carilion Roanoke Memorial Hospital (CRMH) Palliative Care Service and Associate Professor at the Virginia Tech Carilion School of Medicine. Dr. Whitehead has done numerous presentations and publications on advance care planning, pain and symptom management, opioid induced sedation, moral distress, and patients’ end of life preferences locally, regionally, nationally and internationally. Her research interests include improving communication with seriously ill patients and has been funded for numerous grants for her research. In 2021 she was inducted into the American Academy of Nursing as a Fellow.