Advance care planning addresses a question that often goes unspoken: “What matters to you?”

If faced with a medical crisis, advance care planning outlines decisions about the healthcare an individual would want to receive. These decisions are based on personal values, preferences and discussions with loved ones. Advance care planning conversations should be seen as a normal part of life and of a person’s ongoing healthcare plan. 

Asking a patient ‘what matters to them’ will help you work together to begin to identify the patient’s goals, values and wishes. This lets you, your patient, and their family explore treatment options and develop a plan that reflects their wishes.


80% of people say that if seriously ill, they would want to talk to their doctor about wishes for medical treatment toward the end of their life.

18% report having had this conversation with their doctor.

Source: Survey of Californians by the California HealthCare Foundation (2012) and Kaiser Family Foundation Serious Illness in Late Life Survey (2017)

There are many benefits of bringing up the conversation with your patients:

  • Reducing hospitalization
  • Receiving fewer intensive treatments at the end of life
  • Increasing the use of hospice services and
  • Improving the ability for a patient to die in their preferred place

As a healthcare community, we can begin the advance care planning conversations not only to avoid unwanted medical interventions, but to ensure that patient wishes are followed. Questions to be asked could include:

  • What are your goals for your care and how can I help you?
  • I noticed you do not have a health care proxy/directive, would you like to learn more about what it means to have one?
  • What goals are most important if your health situation worsens?
  • What concerns you most when you think about your health and healthcare in the future?
  • Have you shared your personal values with loved ones?

Ideally, advance care planning will result in a formal, written Advance Care Directive (values and/or instructional), to help ensure the person’s preferences are respected. If the person at some point in time is not able to make decisions for themselves, or cannot communicate, their Advance Care Directive guides the person’s family and doctors in making treatment decisions. 

State-Based Resources | Upcoming Webinar 

In order to meet South Dakota’s need for advance care planning, the University of South Dakota’s (USD) Department of Nursing assembled an interdisciplinary, collaborative network of health professionals – Advanced Care Planning: Quality Conversations. Since 2015, this coalition has come together to discuss strategies that help implement advance care planning across South Dakota.

Honoring Choices North Dakota is a collaborative group of statewide community partners who have a shared vision of creating a culture across North Dakota where continuous (on-going) advance care planning is the standard of care and every individual’s informed preferences for care are documented and upheld. 

Save the date: November 11 at 1:00 p.m. CT – We will be hosting a Webinar on this important topic. Nancy Joyner, Honoring Choices will be our featured speaker. 

Free Advance Care Planning Resources