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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26119.
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Laurene Graig, Kaitlyn Friedman, and Joe Alper, Rapporteurs Roundtable on Quality Care for People with Serious Illness Board on Health Care Services Board on Health Sciences Policy Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by Task Order No. 75N98F20P00009 with the National Institutes of Health’s National Institute of Nursing Research and by the American Academy of Hospice and Palliative Medicine, American Geriatrics Society, Anthem, A ­ scension Health, Association of Professional Chaplains, Association of Rehabilitation Nurses, Blue Cross Blue Shield Association, Blue Cross Blue Shield of Arizona, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of North Carolina, The California State University Shiley Institute for Palliative Care, Cambia Health Solutions, Cedars-Sinai Health System, Center to Advance Palliative Care, Centers for Medicare & Medicaid Services, Coalition to Transform Advanced Care, Excellus BlueCross BlueShield, Gordon and Betty Moore Foundation, The Greenwall Foundation, The John A. Hartford Foundation, Hospice & Palliative Nurses Association, Humana, Kaiser ­ ermanente, National Academy for State Health Policy, National Coalition P for Hospice and Palliative Care, National Hospice and Palliative Care Organization, National Palliative Care Research Center, National Patient Advocate Foundation, The New York Academy of Medicine, Patient-Centered Outcomes Research Institute, Social Work Hospice & Palliative Care Network, Supportive Care Coalition, University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, and the National Academy of Medicine. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26119 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2021 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. The challenges and opportunities of advance care planning: Proceedings of a workshop. ­ ashington, DC: The National Academies Press. https://doi.org/10.17226/26119. W PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technol- ogy. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objec- tive analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE FOR A VIRTUAL WORKSHOP ON ADVANCE CARE PLANNING: CHALLENGES AND OPPORTUNITIES1 ROBERT M. ARNOLD (Co-Chair), Distinguished Service Professor of Medicine, University of Pittsburgh Medical Center JOANNE REIFSNYDER (Co-Chair), Executive Vice President, Clinical Operations, and Chief Nursing Officer, Genesis HealthCare (representing the Hospice and Palliative Care Nurses Association) PATRICIA A. BOMBA, Vice President and Medical Director, Geriatrics, Excellus BlueCross BlueShield, Chair, MOLST Statewide Implementation Team, Program Director, eMOLST, Chair, National Healthcare Decisions Day JANE CARMODY, Program Officer, The John A. Hartford Foundation ANNA GOSLINE, Senior Director of Strategic Initiatives, Blue Cross Blue Shield of Massachusetts; Executive Director, Massachusetts Coalition for Serious Illness Care DENISE HESS, Director, Supportive Care Coalition, Catholic Health Association (representing the Association of Professional Chaplains) HAIDEN HUSKAMP, 30th Anniversary Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School KIMBERLY SHERELL JOHNSON, Associate Professor of Medicine, Senior Fellow in the Center for the Study of Aging and Human Development, Duke University School of Medicine REBECCA A. KIRCH, Executive Vice President, Policy and Programs, National Patient Advocate Foundation BERNARD LO, President Emeritus, The Greenwall Foundation R. SEAN MORRISON, Co-Director, Patty and Jay Baker National Palliative Care Center, Director, National Palliative Care Research Center, Director, Hertzberg Palliative Care Institute, Hermann Merkin Professor of Palliative Care, Professor of Geriatrics and Palliative Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. ­ The responsibility for the published Proceedings of a Workshop rests with the workshop r ­ apporteurs and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

JUDITH R. PERES, Board Member, Social Work Hospice and Palliative Care Network LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California REBECCA SUDORE, Professor of Medicine, University of California, San Francisco JAMES A. TULSKY, Chair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Chief, Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, and Co-Director, Harvard Medical School Center for Palliative Care, and Professor of Medicine, Harvard Medical School Project Staff LAURENE GRAIG, Director, Roundtable on Quality Care for People with Serious Illness KAITLYN FRIEDMAN, Associate Program Officer ANESIA WILKS, Senior Program Assistant SHARYL NASS, Senior Director, Board on Health Care Services, and Director, National Cancer Policy Forum Consultant JOE ALPER, Consulting Writer vi PREPUBLICATION COPY—Uncorrected Proofs

ROUNDTABLE ON QUALITY CARE FOR PEOPLE WITH SERIOUS ILLNESS1 PEGGY MAGUIRE (Co-Chair), President and Board Chair, Cambia Health Foundation JAMES A. TULSKY (Co-Chair), Chair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Chief, Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, and Co-Director, Harvard Medical School Center for Palliative Care, and Professor of Medicine, Harvard Medical School KIRK ALLEN, Senior Vice President, Home Care, Humana JENNIFER BALLENTINE, Executive Director, The California State University Shiley Institute for Palliative Care ROBERT A. BERGAMINI, SSM Health (representing the Supportive Care Coalition) LORI BISHOP, Vice President of Palliative and Advanced Care, National Hospice and Palliative Care Organization PATRICIA A. BOMBA, Vice President and Medical Director, Geriatrics, Excellus BlueCross BlueShield, Chair, MOLST Statewide Implementation Team, Program Director, eMOLST, Chair, National Healthcare Decisions Day KAREN BULLOCK, Professor, John A. Hartford Faculty Scholar, Department of Social Work, North Carolina State University (representing the Social Work Hospice and Palliative Care Network) GRACE B. CAMPBELL, Assistant Professor, Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing (representing the Association of Rehabilitation Nurses) JOHN CAMPBELL, Senior Medical Director, Clinical Effectiveness, Blue Cross Blue Shield of North Carolina JANE CARMODY, Program Officer, The John A. Hartford Foundation STEVE CLAUSER, Director, Healthcare Delivery and Disparities Research Program, Patient-Centered Outcomes Research Institute 1 The National Academies of Sciences, Engineering, and Medicine’s forums and round- tables do not issue, review, or approve individual documents. The responsibility for the pub- lished Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

SARAH DAMIANO, Director, Palliative Care, Clinical and Network Services, Ascension Health DAVID J. DEBONO, National Medical Directory for Oncology, Anthem CAROLE REDDING FLAMM, Executive Medical Director, Center for Clinical Value, Office of Clinical Affairs, Blue Cross Blue Shield Association ANNA GOSLINE, Senior Director of Strategic Initiatives, Blue Cross Blue Shield of Massachusetts; Executive Director, Massachusetts Coalition for Serious Illness Care MICHELLE GROMAN, President and Chief Executive Officer, The Greenwell Foundation DENISE HESS, Director, Supportive Care Coalition, Catholic Health Association (representing the Association of Professional Chaplains) PAMELA S. HINDS, Director and Professor, Conway Chair in Nursing Research, Director Nursing Research and Quality Outcomes, Children’s National Health System HAIDEN HUSKAMP, 30th Anniversary Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School KIMBERLY SHERELL JOHNSON, Associate Professor of Medicine, Senior Fellow in the Center for the Study of Aging and Human Development, Duke University School of Medicine REBECCA A. KIRCH, Executive Vice President, Policy and Programs, National Patient Advocate Foundation TOM KOUTSOUMPAS, Co-Founder, Coalition to Transform Advanced Care, President and Chief Executive Officer, National Partnership for Hospice Innovation SHARI M. LING, Deputy Chief Medical Officer, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services DIANE E. MEIER, Director, Center to Advance Palliative Care, Gaisman Professor of Medical Ethics, Vice Chair for Public Policy and Professor, Department of Geriatrics and Palliative Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai AMY MELNICK, Executive Director, National Coalition for Hospice and Palliative Care JERI L. MILLER, Chief, Office of End-of-Life and Palliative Care Research, Senior Policy Analysis, Division of Extramural Science Programs, National Institute of Nursing Research, National Institutes of Health viii PREPUBLICATION COPY—Uncorrected Proofs

R. SEAN MORRISON, Co-Director, Patty and Jay Baker National Palliative Care Center, Director, National Palliative Care Research Center, Director, Hertzberg Palliative Care Institute, Hermann Merkin Professor of Palliative Care, Professor of Geriatrics and Palliative Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai PHILIP A. PIZZO, Founding Director, Stanford Distinguished Careers Institute, Former Dean and David and Susan Heckerman Professor of Pediatrics and of Microbiology and Immunology, Stanford School of Medicine THOMAS M. PRISELAC, President and Chief Executive Officer, Cedars-Sinai Health System KITTY PURINGTON, Senior Program Director, National Academy for State Health Policy RUBINA RAJA, Medical Director, Operations, Blue Cross Blue Shield of Arizona JOANNE REIFSNYDER, Executive Vice President, Clinical Operations and Chief Nursing Officer, Genesis HealthCare (representing the Hospice and Palliative Nurses Association) PHILLIP RODGERS, Professor, Family Medicine and Internal Medicine, Director, Adult Palliative Medicine Clinical Programs, University of Michigan (representing the American Academy of Hospice and Palliative Medicine) JUDITH A. SALERNO, President, The New York Academy of Medicine LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California JOSEPH W. SHEGA, Senior Vice President and Chief Medical Officer, VITAS Hospice Care (representing the American Geriatrics Society) SUSAN ELIZABETH WANG, WLA Chief, Department of Geriatrics, Palliative, and Continuing Care, Fellowship Director, Palliative Medicine, Regional Lead, Shared Decision-Making and Advance Care Planning, Southern California Permanente Medical Group, Kaiser Permanente Roundtable on Quality Care for People with Serious Illness Staff LAURENE GRAIG, Director, Roundtable on Quality Care for People with Serious Illness KAITLYN FRIEDMAN, Associate Program Officer ix PREPUBLICATION COPY—Uncorrected Proofs

ANESIA WILKS, Senior Program Assistant MICAH WINOGRAD, Senior Finance Business Partner SHARYL NASS, Senior Director, Board on Health Care Services, and Director, National Cancer Policy Forum ANDREW M. POPE, Senior Director, Board on Health Sciences Policy x PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com- ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: RANDALL CURTIS, Cambia Palliative Care Center of Excellence, University of Washington SUSAN HICKMAN, Regenstreif Institute, Indiana University Schools of Nursing and Medicine, IUPUI RESPECT Signature Center MILDRED Z. SOLOMON, The Hastings Center Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by KATHLEEN UNROE, Indiana Univer- sity Center for Aging and Indiana University School of Medicine. She was responsible for making certain that an independent examination of this xi PREPUBLICATION COPY—Uncorrected Proofs

xii REVIEWERS proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Respon- sibility for the final content rests entirely with the rapporteurs and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs

Acknowledgments The National Academies of Sciences, Engineering, and Medicine’s Roundtable on Quality Care for People with Serious Illness wishes to express its sincere gratitude to the planning committee co-chairs Robert Arnold and JoAnne Reifsnyder for their valuable contributions to the development and orchestration of this workshop. The roundtable also wishes to thank all the members of the planning committee, who collaborated to ensure a work- shop replete with informative presentations and rich discussions. Finally, the roundtable wants to thank the speakers and moderators, who generously shared their expertise and their time with workshop participants. Support from the many annual sponsors of the Roundtable on ­ uality Q Care for People with Serious Illness is critical to its work. The sponsors include the National Institutes of Health’s National Institute of Nursing Research and the American Academy of Hospice and Palliative Medicine, American G ­ eriatrics Society, Anthem, Ascension Health, Association of Professional Chaplains, Association of Rehabilitation Nurses, Blue Cross Blue Shield Association, Blue Cross Blue Shield of Arizona, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of North Carolina, The California­ State University Shiley Institute for Palliative Care, Cambia Health Solutions, ­ Cedars-Sinai Health System, Center to Advance Palliative Care, Centers for Medicare & Medicaid Services, Coalition to Transform Advanced Care, Excellus BlueCross BlueShield, Gordon and Betty Moore Foundation, The ­ reenwall Foundation, The John A. Hartford Foundation, Hospice G xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv ACKNOWLEDGMENTS & Palliative Nurses Association, Humana, Kaiser Permanente, National ­ A ­ cademy for State Health Policy, National Coalition for Hospice and P ­ alliative Care, National Hospice and Palliative Care Organization, National Palliative Care Research Center, National Patient Advocate Foundation, The New York Academy of Medicine, Patient-Centered Outcomes Research Institute, Social Work Hospice & Palliative Care Network, Supportive Care Coalition, University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, and the National Academy of Medicine. PREPUBLICATION COPY—Uncorrected Proofs

Contents ACRONYMS AND ABBREVIATIONS xix PROCEEDINGS OF A WORKSHOP 1 INTRODUCTION 1 OPENING REMARKS 2 THE PARADOX OF ADVANCE CARE PLANNING 7 Lived Experiences with Advance Care Planning, 7 An Ethical Framework: From Advance Directives to Advance Care Planning, 9 The Complexities of Advance Care Planning: What Are We Even Talking About?, 11 Discussion, 16 INTERPRETING THE EVIDENCE BASE FOR ADVANCE CARE PLANNING 17 What Is the Evidence and Why Does It Matter?, 17 How Clinical and Health Care Leaders Use Advance Care Planning Research, 21 Making Sense of the Evidence, 24 Advance Care Planning Is a Right: A Medical–Legal Perspective, 28 Discussion, 31 A BRIEF SUMMARY OF THE FIRST WEBINAR 35 xv PREPUBLICATION COPY—Uncorrected Proofs

xvi CONTENTS THINKING DIFFERENTLY ABOUT ADVANCE CARE PLANNING 37 Flaws in Advance Care Planning Implementation and Evaluation, 37 Advance Care Planning: Ethical Challenges, 41 Advancing the Language of Advance Care Planning: A Messaging Research Project, 43 Discussion, 46 PRACTICAL STEPS TO MORE EFFECTIVE ADVANCE CARE PLANNING 48 The Importance of Patients’ and Families’ Nonmedical Concerns, 48 Implementing Advance Care Planning in the Hospital Setting, 50 The Health System Perspective on Practical Steps to More Effective Advance Care Planning, 51 Discussion, 54 PANEL DISCUSSION 57 CLOSING REMARKS 62 REFERENCES 62 APPENDIX A: Statement of Task 69 APPENDIX B: Workshop Agenda 71 PREPUBLICATION COPY—Uncorrected Proofs

Box, Figures, and Table BOX 1 Suggestions Made by Individual Workshop Participants to Address the Challenges and Opportunities for Advance Care Planning (ACP), 3 FIGURES 1  model showing how the conversations about advance care planning A and documentation may differ from decisions about goals of care or consent for treatment, 13 2  continuum of communication and decision making in serious The illness care, 26 3 Advanced serious illness preparation and planning, 28 4 Seriously ill, hospitalized patients rated whether various states of functional disability were better or worse than death, 39 TABLE 1 Five Messages Supporting Advance Care Planning, 45 xvii PREPUBLICATION COPY—Uncorrected Proofs

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Acronyms and Abbreviations ACP advance care planning CCCC Community Conversations on Compassionate Care CPR cardiopulmonary resuscitation ED emergency department EHR electronic health record ICU intensive care unit MOLST medical orders for life-sustaining treatment NPAF National Patient Advocate Foundation POLST physician orders for life-sustaining treatment PTSD posttraumatic stress disorder RCT randomized controlled trial xix PREPUBLICATION COPY—Uncorrected Proofs

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Advance Care Planning(ACP)has long been a staple of caring for people with serious illness. Over its history, it has been defined in different ways. Clinicians, researchers, patients, and the public have developed a variety of perspectives about the many aspects of ACP, ranging from the definition to the timing, goals, outcomes, and value of ACP.

To better understand the challenges and opportunities for ACP, acknowledge and highlight divergent viewpoints, and examine what is empirically known and not known about ACP and its outcomes, the National Academies of Sciences, Engineering, and Medicine's Roundtable on Quality Care for People with Serious Illness hosted a virtual public workshop, Advance Care Planning: Challenges and Opportunities, on October 26 and November 2, 2020. The workshop explored the paradox of ACP, its evidence base, ways to think differently about ACP, and various approaches to making it more effective.This Proceedings of a Workshop summarizes the presentations and discussions from that workshop.

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