TABLE 3.2 Adapting Advance Care Planning to Patient Circumstances: Possible Issues and Actions
| Health status | Issues for discussion | Actions | Persons to lead action |
| Healthy | Surrogate decisionmaker | Suggest completion of durable power of attorney | C |
| Health concerns | Discuss possibilities in a medical emergency | C, P | |
| Preferences or beliefs | Discuss values and preferences with surrogate | P | |
| Document strong preferences in patient record | C | ||
| Diagnosis of serious illness | Surrogate decisionmaker | Complete durable power of attorney | P |
| Prognosis and options | Discuss possible and likely outcome states in relation to care options | C, P, F | |
| Preferences or beliefs | Discuss values and preferences in the event of an emergency | P | |
| Document preferences in patient record | C | ||
| Diagnosis of life-threatening illness | Surrogate decisionmaker | Determine status and location of durable power of attorney documents | C, P, F |
| Preferences | Discuss and document preferences for end-of-life care and make arrangements as appropriate | C, P, F | |
| Goals | Discuss hopes and expectations for the last stage of life | C, P | |
| Contingency plans | Make specific plans for likely complications and urgent situations | C, P, F | |
| Advanced age | Surrogate decisionmaker | Determine status and location of durable power of attorney documents | C, P, F |
| Preferences | Discuss and document preferences for end-of-life care and make arrangements as appropriate | C, P, F | |
| Goals | Discuss hopes and expectations for the last stage of life | C, P | |
| Contingency plans | Make specific plans for likely complications and urgent situations | C, F | |
NOTE: C, caregiver, P, patient; F, family. SOURCE: Adapted from Teno and Lynn, 1966.