5 Steps to Creating a Personalized Advance Care Plan

Advance Care Planning means thinking about and deciding on the type of medical care you would want if you had a life-threatening illness. It is an umbrella term that also includes documentation of your preferences through “Advance Care Directives”.  You are never too young, too healthy, or too old to start these conversations. The COVID-19 pandemic made it very clear how critical it is to contemplate your wishes and to share it with others, in advance of a critical illness.  

Here are 5 steps to help you create a personalized Advance Care Plan.  

Step One: Think About It 

Think about what a good day looks like for you.  You are the expert in what matters most to you. Consider the following questions to get started. 

What does a good day look like?  

Some people would want to spend time with friends or family or their pet, watch TV, or enjoy a particular activity.  

How could a serious illness change your good days? 

Consider what you need from your health to ensure good days and then think about what your days would look like if your health status changed.  

If you were very sick, and time were short, what would you want to do with that time? Where would you want to spend it?  

Some people want to spend time at home with loved ones, others prefer to be in a nursing home or a hospital where others can take care of their medical needs and their loved ones can visit.   

When would it be okay to shift from curative medical care to comfort focused medical care? 

Some people would say that when they are unable to communicate with others and unable to partake in the activities that make up a “good day”, while others may wish to reach a particular milestone.  

Who would speak for you if you couldn’t share your wishes yourself?  

This is someone who knows you well, who could speak about what matters most to you, and who would make decisions consistent with your wishes. Some people assign a family member, or a partner, or a friend to be the spokesperson if they are unable to communicate themselves.  

Step Two: Talk About It 

Talk with a trusted friend or family member or healthcare provider about what is most important to you. Share with them your answers to the questions in step one.  

This process may uncover questions for your doctors about your health or about life-sustaining interventions such as cardiopulmonary resuscitation (attempts to restart your heart and breathing), intubation (using a ventilator to help you breathe), or artificial nutrition (being fed through a tube in your nose or stomach). 

Step Three: Write it down 

An Advance Directive is an umbrella term for the written documentation of your healthcare wishes and choices. These documents provide your loved ones and your healthcare team a roadmap to take better care of you. Advanced Directives are not set in stone and can be revised and reassessed at any time.  Here are the most common Advance Directives: 

Health Care Proxy or Durable Power of Attorney of Health Care

This document identifies your health care decision maker, the person who would speak on your behalf if you could not speak for yourself. This is an individual with whom you can discuss your healthcare wishes and whom you trust to share this information with your healthcare team.  

Orders for life sustaining treatment (POLST/MOLST/COLST/MOST) 

The form is a healthcare provider’s written medical order documenting your preferences regarding life sustaining treatments such as: resuscitation, intubation, hemodialysis, artificial nutrition and hydration, blood transfusion, antibiotics, and hospitalization. The form is state-specific and it is the only legally binding, medical order for preferences regarding cardio-pulmonary resuscitation (CPR) in the non-the hospital setting. Complete the form together with your healthcare provider. 

Living Will 

This is a legal document that specifies the type of medical treatments an individual wants or does not want at the end-of-life. These wishes can guide medical decisions if you are terminally ill or permanently unconscious. Living wills vary from state to state.  

Step Four: Share it 

Share your wishes, choices, and documentation with your healthcare proxy, close family or friends, and with your healthcare team.  

Step Five: Revise it 

As your health changes, how you define a good day may change. This is normal.  You may need to revise and update the Advance Directive to reflect your current wishes. Importantly, keep the conversation going with your friends, family, and your healthcare providers, that way they can respect and honor your wishes in the future.  

Our Coaches Can Help  

Our empathic coaches offer one-on-one, virtual, advance care planning  sessions to individuals throughout the US. We help you explore what’s important to you and develop or update an advance care plan. We harness our expertise to empower you to live well. To get you started, take the free 7-Day Advance Care Planning Challenge!

Caitlin Baran M.D. is a Palliative Care physician and Coach with EpioneMD. She completed completed her fellowship in Hospice & Palliative Medicine at the Harvard Interprofessional Palliative Care program. She has worked at academic centers including Massachusetts General Hospital and was an Instructor in Medicine at Harvard Medical School. Caitlin is humbled to practice Palliative Care, a field of medicine designed to understand who people are and align healthcare choices with their values.



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