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Advance Care Planning


Advance Care Planning can be an intimidating and unfamiliar process for many people. This resource library was created to provide additional information and tools which can be used to compliment class attendance and assist in completing your Advance Care Plan.

Use the resources listed here to educate yourself and make decisions about your end-of-life wishes. Or share this information with a loved one so they can do the same.

Did you know?

  • Eighty percent of patients want to die at home, but only 20 to 25 percent actually do. An advance directive can help your wishes be made known to loved ones and medical professionals.
  • Eighteen to 20 percent of patients die in an ICU.
  • The average American sees 10 different physicians in the last six months of life. Do your physicians know your end-of-life wishes?
  • Approximately 94 percent of patients with severe illness want their physician to know their wishes for end of life
  • Fewer than 20 percent of patients with severe illness think their physician knows their wishes.

Creating Your Plan

  • Ottawa Personal Decision Guide – The Ottawa Personal Decision Guide (OPDG) and Ottawa Personal Decision Guide for Two (OPDGx2) are designed for any health-related or social decisions. They can help people identify their decision making needs, plan the next steps, track their progress, and share their views about the decision.
  • The Conversation Project – starter kit – It’s not easy to talk about how you want the end of your life to be. But it’s one of the most important conversations you can have with your loved ones. This Start Kit will help you get your thoughts together and then have the conversation. This isn’t about filling out Advance Directives or other medical forms. It’s about talking to your loved ones about what you or they want for end-of-life care.
  • IOM Report on Dying in America – A substantial body of evidence shows that broad improvements to end-of-life care are within reach. In Dying in America, a consensus report from the Institute of Medicine (IOM), a committee of experts finds that improving the quality and availability of medical and social services for patients and their families could not only enhance quality of life through the end of life, but may also contribute to a more sustainable care system.
  • – The video, Speaking of Dying captures the importance of individuals and groups speaking openly about all aspects of the dying process. Viewing this film will inspire and encourage you to talk to your friends, family, health care agents and medical providers about your own end-of-life choices and wishes.
  • Consider the Conversation – A documentary on a Taboo Subject is available for purchase on Two DVD products have been created, each with unique licensing terms – one for personal use (private viewing in the home) and one for education use (public showings in front of a non-paying audience).
  • Washington Default Decision Process – In the absence of an advance directive, medical decisions for an incompetent person are made by a surrogate decision-maker. In Washington, the persons authorized to make medical decisions on behalf of an incompetent individual.
  • Check list – An easy to follow checklist walking you through the steps of creating/completing your Advance Care Plan
  • Respecting Choices® Glossary of Terms – Not sure what some of the terminology means? Download your personal cheat sheet to ACP terms.
  • Washington State Health Advocacy Association (WASHAA) – Aims to help patients and their families or caregivers struggling to understand and access the health care system.

Documenting Your Plan

  • Respecting Choices®/Gundersen: Respecting Choices® (RC) is an internationally recognized, evidence-based model of advance care planning (ACP) that creates a healthcare culture of person-centered care; care that honors an individual’s goals and values for current and future healthcare. This link provides you with background on the material presented at the Coalition classes. The Coalition has a licensing agreement and is certified to teach using this information.
  • WA State Catholic ConferenceGuide to making good decisions for the end of life (English and Spanish) A Guide to Making Good Decisions for the End of Life: Living Will and Durable Power of Attorney for Health Care.  Prepared by the Catholic Bishops of Washington State, this booklet is a practical resource to assist Catholics in making choices about health care decisions for the end of life.  It provides an overview of Catholic teachings on end-of-life decision-making as well as forms for “living will” and Durable Power of Attorney for Health Care and guidance on how to fill out those forms. The booklet also contains answers to common end-of-life questions and a helpful section on making funeral plans. The booklet can be downloaded and printed in both English and Spanish.
  • Alzheimer’s Disease and Dementia advance directives: This first-of-its-kind advance planning document allows people coping with Alzheimer’s disease and dementia to document their wishes about the inevitable challenges related to living with these illnesses. Completing this document with the help of professionals, such as a mental health professional, geriatric care manager, and/or an elder law attorney, is highly recommended.
  • 5 Wishes
  • A legal document that helps adults of all ages plan for care in case they become seriously ill.
  • Allows adults to name a person to make health decisions for them and to give you instruction about life-support treatment.
  • Focuses on human dignity, comfort, spirituality, and personal relationships.
  • Meets statutes for 42 states and the District of Columbia.
  • Complete on screen in English or print out to complete by hand in any of 27 languages.
  • Physician Orders for Life Sustaining Treatment (POLST) The POLST form itemizes wishes of an individual regarding life-sustaining treatment. The form is intended for any individual with a serious illness.
  • The form accomplishes two major purposes:
    • It is portable from one care setting to another
    • It translates wishes of an individual into actual physician orders.
  • An attending physician, ARNP or PA-C must sign the form and assume full responsibility for its accuracy.