Advance Care Planning: How to Have the Conversation You Want With Your Patients


More patients are receiving intensive care in their last days of life, even though studies show that most don't want it. Family physicians are uniquely positioned to make sure patients' wishes are recorded and respected.

Fam Pract Manag. 2019 Nov-Dec;26(6):18-22.

Author disclosure: no relevant financial affiliations disclosed.

My patient's name was Tom, and I had been his primary care physician for almost 20 years. He was in his 80s and a “retired” farmer, which meant he worked 40 hours a week instead of 80. He came in for a Medicare annual wellness visit (AWV) one day, and I told him I was embarrassed that in all our time together I had never talked with him about advance care planning.

I said that although he was healthy I needed to ask if he had any documents that detailed what life-saving or life-sustaining measures he would want taken — or not taken — if his health dramatically changed. Would he want to be intubated or have CPR if his heartbeat or breathing stopped?

Tom, a very taciturn man, looked at me and replied, “If you bring me back from the dead, I will haunt you.”

We filled out a form that day to specify Tom's advance care planning wishes, including a do-not-resuscitate (DNR) order.

Advance care planning (ACP) is one of the most important ways you can help honor your patients' wishes. Studies show that most patients would rather die at home than in a hospital or nursing home,1 and if asked to put their wishes in writing, 9 out of 10 say they want limited care or only comfort care at the end of their lives.2 But a quarter of Medicare beneficiaries still die in acute care hospitals, and the percentage of patients who receive intensive care, or undergo multiple transitions of care, during the final 30 days of life has increased.3 Most of us have known patients who did not have advance directives and spent their final days in intensive care units undergoing multiple, costly interventions they did not want and enduring unnecessary stress and discomfort for themselves and their loved ones.

To change this, the Centers for Medicare & Medicaid Services (CMS) in 2016 began paying for ACP, and some private insurers have followed suit (see “Coding, billing, and documentation for advance care planning”).

Any physician or other qualified health care professional can bill for ACP if they explain and discuss advance directives face-to-face with patients, their family members, or surrogates. The codes also cover the time needed to complete forms.

Physicians and patients were discussing advance directives long before CMS offered payment for it, but many patients still do not have the conversation, or if they do, it's not until the very end of life.4 This is unfortunate, because earlier ACP discussions can prevent aggressive treatments that negatively affect patients and their caregivers.5


  • Advance care planning (ACP) is an ongoing conversation about your patients' wishes for the end of their lives. Their advance directives can be discussed and revised as many times as necessary.

  • Discussions about the end of life can be uncomfortable for patient and physician, but the earlier they begin, the better. If you wait until the patient is near death, when the situation is often chaotic and stressful, they can be even more difficult.

  • ACP can be billed


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Dr. Brull is a family physician and owner of Prairie Star Family Practice in Plainville, Kan. She is also regional medical director for Aledade, working with three accountable care organizations made up of independent primary care practices in Kansas, Oklahoma, and eastern Missouri....

Author disclosure: no relevant financial affiliations disclosed.

Note: All patient names have been changed.


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1. Barnato AE, Herndon MB, Anthony DL, et al. Are regional variations in end-of-life care intensity explained by patient preferences? Med Care. 2007;45(5):386–393....

2. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211–1218.

3. Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470–477.

4. Mack JW, Cronin A, Taback N, et al. End-of-life care discussions among patients with advanced cancer: a cohort study. Ann Intern Med. 2012;156(3):204–210.

5. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665–1673.


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