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Difficult but necessary conversations — the case for advance care planning

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Modern medicine saves many people from acute illness who then live longer with chronic illnesses associated with trajectories of declining physical and mental function over months and years, often punctuated by episodes of acute illness or decompensation. Regrettably, considerable suffering as well as dissatisfaction with and overuse of health care result from a mismatch between the needs of chronically ill patients and current practice norms. Advance care planning (ACP) provides a means of ameliorating this mismatch but is yet to be embedded in routine clinical practice or public consciousness.

ACP is a process of making decisions about future health care for patients in consultation with clinicians, family members and important others. It aims to ensure patients’ wishes are respected if they lose decisional capacity. Conceptually, it comprises five sequential phases, from pre-contemplation to action and maintenance (Appendix 1),1 which include completion of a written advance care plan (or advance health directive [AHD], also termed “living will”) and the appointment of a surrogate decisionmaker. Unfortunately, in the past, ACP has often been focused…