1. What is Advance Care Planning?

Advance Care Planning (ACP) is a process of reflection, communication, and sometimes education that allows individuals to determine their personal goals for future healthcare in the context of their values and beliefs. This lets us plan ahead and prepare for future needs and medical care (preferably before a crisis) and to choose someone to speak for us in the event that we are not able to speak for ourselves. Thoughtful ACP involves communication of these wishes through conversations and documents.

2. Why is ACP important?

At some point in our lives, 50% of us will be unable to make medical decisions for ourselves. This is why intentional appointment of an informed healthcare agent (or “medical decision-maker”) is so crucial to making sure we get the care we want. In Colorado, if you have not appointed a healthcare agent in writing through a document called a Medical Durable Power of Attorney (MDPOA) the law allows any “interested party” to become involved in decisions about your healthcare

3. Isn’t my spouse (or parent, or adult child) automatically my healthcare decision-maker?

No. Without this document, physicians in Colorado are legally obligated to listen to all “interested parties.” The vast majority of other states have healthcare proxy statutes that do follow a spouse-adult child-parent protocol for decision-makers.

4. Do I need to go to a lawyer?

No. An MDPOA is a simple form that can be filled out by individuals without the help of an attorney. Once dated and signed, it is a legal document. There is an optional second page where you can have your signature notarized and/or have your agent sign as well, but this is not necessary. We have these forms available and can help you with the process.

5. My (children/spouse/parents) don’t want to talk about this.

We are not talking about death and dying, but about living fully and addressing quality of life issues while we are fully able to do so. Most people don’t want to “be a burden” to their families, and yet failing to make your wishes clear often results in a terrible burden to family; they are left without direction or understanding of your needs and choices. Families feel guilty, and the legacy is often one of stress and pain.

We have tools and resources, “conversation starters,” videos and prompts that can help you engage with your loved ones in meaningful conversations around future care.

6. I’m young and healthy! I don’t need to do this.

This is exactly the time to start simple ACP. Everyone over 18 should have an MDPOA and the process of talking to loved ones about your personal values is a very rich experience at any age.

7. But I’ve done all this. I have a DNR.

Chances are you do NOT have a DNR. You likely have a document called a Living Will or Advanced Directive with certain checklist care choices (like DNR, no CPR, no intubation etc.). These are effective under very limited circumstances – you must be unable to make decisions AND two physicians must agree that you are terminal or in a chronic vegetative state.

An effective DNR or “no CPR” directive must be signed by a physician. We can teach you about MOST and POLST forms, as well as other advance directives that are physicians orders for treatment.

Even if you have written advance directives, unless you have engaged in conversations with loved ones about your future choices, there may be great misunderstanding, stress and strife in times of crisis. Sound ACP involves a true communication process with loved ones and clinicians; we specialize in opening up the circle for dialogue and then closing all loops with the healthcare system.

8. I want to die at home. How can I make this happen?

Research shows that 70% of us want to die at home, and yet 70% die in institutions (hospitals, skilled nursing facilities, etc.). The best way to assure your wishes are respected is advance care planning with family – thoughtful values-based conversations and the appointment of a fully informed decision-maker.

Consider these facts…

  • 90% of people say that talking with their loved ones about end-of-life care is important.
  • 27% have actually done so. (Source: The Conversation Project National Survey (2013) )
  • 60% of people say that making sure their family is not burdened by tough decisions is extremely important.
  • 56% have not communicated their end-of life 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.
  • 7% report having had this conversation with their doctor.
  • 82% of people say it’s important to put their wishes in writing.
  • 23% have actually done it.

Source: Survey of Californians by the California HealthCare Foundation (2012)

FAQs for Physicians and Healthcare Providers:

  • Patients who choose less aggressive end of life treatment LIVE LONGER;
  • Strong end of life planning overall (Advanced Directives, palliative team planning, hospice, and POSLT/MOST system) is effective in reducing readmission rates as well as PATIENT SUFFERING.
  • Palliative care consults for high risk ED and ICU admissions have proven effective in lowering readmissions;
  • When patients desire and are referred for hospice services, hospitalization rates in the subsequent 30 to 180 days are decreased by 40% to 50%
    Sharon Silow-Carroll, Jennifer n. Edwards, and Aimee Lashbrook, reducing hospital readmissions: lessons from top-performing hospitals, Health Management Associates, April 2011
  • Patients who have advance care planning spend 10 fewer days in the hospital during their last two years and have fewer readmissions than those without, as many elect to spend the time at home with family.

“Advanced Illness Management Strategies – Part 1” Web. 3 Nov. 2013. http://www.aha.org/ about/org/aim-strategies.html


Repeat ED and hospital admissions are often demographic and disease-specific. In one study from the New England Journal of Medicine, these facts emerged:

  • 6% of Medicare beneficiaries were readmitted to the hospital within 30 days of discharge, and 34.0% were readmitted within 90 days.
  • Medical and surgical patients were both affected, though medical patients had a higher readmission rate (21.1% vs. 15.6% among surgical patients at 30 days) and accounted for 77.1% of the re-hospitalizations.
  • The highest 30-day readmission rates were observed for patients with heart failure (26.9%), psychoses (24.6%), recent vascular surgery (23.9%), chronic obstructive pulmonary disease (22.6%), and pneumonia (20.1%). During the last decade, risk-adjusted 30-day readmission rates among Medicare beneficiaries have remained relatively constant.


  • The average national re-admit rate for ICU is 7%
  • 1 in 5 Medicare patients re-admit within 30 days
  • 1 in 3 Medicare patients re-admit within 90 days
  • 14-17% general population re-admit within 30 days
  • 30 day re-admissions cost Medicare$12-15 billion

Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N. Engl. J. Med. 2012;366:1366–9

If you can target “at risk” patients and give them resources to make medical decisions in advance, it will likely lessen ED/ICU utilization and 30-day readmissions.