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Your office staff can help normalize conversations with patients about critical care options.

Fam Pract Manag. 2022;29(3):10-14

This content conforms to AAFP criteria for CME.

Author disclosures: no relevant financial relationships.

The need for patients to document their critical care preferences through advance directives existed long before the COVID-19 pandemic. But the pandemic caused a sudden increase in procedures such as mechanical ventilation, often without family members present, which has driven home the importance of having these sometimes-difficult conversations with a trusted primary care clinician before patients are seriously ill.

Advance care planning (ACP) gives patients the information they need to create a legal document (sometimes called a “living will”) that outlines the care they want if they are unable to voice their wishes due to physical or cognitive disability. This includes naming a health care agent (HCA) authorized to make decisions on the patient's behalf, who can also be named in a separate medical/durable power of attorney document.

Advance directives are recommended for all adults, but in the U.S. only about 37% of adults have completed them.1 Barriers to completion include visit time constraints, clinician discomfort with end-of-life discussions, and lack of patient awareness of ACP.2

The most effective way to increase ACP completion in primary care settings is repeated face-to-face patient counseling by a health care professional.3 But it's not practical for physicians to do this alone in most practices.

However, there are a number of ways practices can leverage their EHRs and clinic staff to prep patients for ACP conversations and increase ACP completion rates. Our clinic created a team-based workflow and educational tools to encourage these conversations without adding clinician effort or cost.

Our workflow uses the EHR, the full clinic staff, and pre-visit waiting time to prime patients for ACP discussions, ensuring clinician time is used only for the complex, clinical aspects of ACP. Our educational tool helps patients understand how an HCA functions and what medical procedures should be discussed during ACP. Ideally, this results in patients completing a full set of advance directives, or at least legally identifying an HCA.


  • Developing a health care agent (HCA) patient education form can lead to more patients designating a trusted person to make health care decisions for them if they become incapacitated.

  • Engaging the whole care team in advance care planning (ACP) and HCA designation lightens the clinician's workload and enriches the jobs of other staff.

  • Making ACP/HCA forms a routine part of patient visits normalizes end-of-life care conversations and helps the clinic consistently document patient wishes.


We recommend that clinics start by assessing their current ACP processes and resources. When our clinic did that, we found that our process usually depended on clinicians initiating the ACP discussion, often at a Medicare wellness visit, new patient visit, or annual physical, or when patients were in declining health or facing a terminal diagnosis. Clinicians said that ACP conversations felt forced and unnatural when the visit was about chronic disease or a minor acute issue such as a muscle strain. As a result, many patients were never approached about ACP or designating an HCA.

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