• Long-Term Planning

    Long-term and advance-care planning should occur at a point in the life of a patient before significant cognitive impairments are evident. This section provides resources for the entire care team that includes the clinical practice, families, formal and informal caregivers, and the patient. Physicians can use these resources to help initiate conversations that prepare patients to plan for the aging process.

    • Suggested resources are those that the AAFP panel of experts have chosen as the most effective, comprehensive, and evidence-based information.
    • Additional resources provide additional resources and approaches physicians, patients, families, caregivers and support team members may find useful in providing care for patients with cognitive impairment.

    Suggested Physician Resources

    Five Wishes
    Five Wishes is a resource for creating advanced care directives with your patients in the event of a serious illness or disease. It can be used in all 50 states, with eight states needing to complete it in conjunction with other required forms. It is available in 28 languages. There is a small fee associated with each download.

    Patient, Family, and Caregiver Resources

    The Conversation Project
    The Conversation Project and the Institute for Healthcare Improvement developed a resource for patients, families, and caregivers to discuss matters of end-of-life care. The Conversation Starter Kit, along with other resources can be downloaded from the site.

    Advance Care Planning Fact Sheet
    The National Institute on Aging’s fact sheet contains information for patients on advanced care planning. This document provides definitions, answers questions patients and families have about making decisions, and how to make the patient’s wishes known.

    The Process of Long-Term Care Planning
    The National Care Planning Council has outlined a seven-step process of long-term care planning, which includes a course of action for patients and families to better understand the planning process. This resource may be used during a physician-patient conversation, or as a take-home resource for patients to discuss and plan with family and other caregivers.

    Senior Health: Planning for Long-Term Care
    The National Institutes of Health Senior Health resource provides information for patients on a variety of aspects of long-term care. Health, financial, legal, housing, and other options are described.

    Legal Planning
    The Alzheimer’s Association offers information and resources on creating a plan for legal issues for patients and families. The information covers the basics of legal planning, documentation needed, and when to get help from an attorney.

    Financial Planning
    The Alzheimer’s Association offers information and resources on financial planning after a diagnosis of Alzheimer’s disease or other dementia. It can aid patients and families in discussions about the cost of care and other professional assistance when dealing with planning for long-term illness and end-of-life care.

    End-of-Life Planning
    The Alzheimer’s Association offers information and resources on end-of-life planning. It provides an outline of conversation points for physicians, patients, families, and other caregivers to discuss sensitive topics related to end-of-life issues.

    Additional Physician Resources

    Advanced Care Planning Resources
    The Center for Practical Bioethics provides information, planning resources, audio interviews, case studies, and articles about advance-care planning.

    Advance Care Planning Worksheet
    Elder care specialists developed this tool to assist in communication between the care team and the patient for end-of-life care wishes. This table is based on language in the POLST (physician orders for life-sustaining treatment). It helps the patient and physician determine the desired level of care for various treatments. The patient can decide if they prefer the treatment, prefer no treatment, or allow the durable power of attorney for health care (DPOAH) to make the decision.