Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.
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Increase the frequency and quality of advanced care planning and documentation.
Evidence supporting implementation of practices/processes to improve advance care planning. Include all of the following elements:
- Documentation approach – Standardized approach to documenting advance care plan or living will within the medical record (e.g., a medical record template or other defined, standardized method to include specific attributes defined by the eligible clinician) and storage of any relevant copies of patient documents when appropriate; AND
- Patient identification – Identification of the population of patients, as defined by the eligible clinician (e.g., all patients over 65, patients with specific diagnoses, all patients) who would be subject to the eligible clinician’s practices/processes for encouraging advance care planning; AND
- Eligible clinician education on advance care planning – Documentation of eligible clinician education (e.g., training curriculum or agenda, training materials) on approaches to advance care planning at the level of the individual patient.