Advance care planning (ACP) identifies a patient's personal preferences for health care in case of chronic, serious illness.  It is a flexible, patient-centered process (ie, prioritizes patient values) that delineates key patient preferences that can then guide medical decision-making.  The process may include (but does not necessitate) creation of legal documents, such as appointment of a surrogate decision maker who acts on the patient's behalf if the patient is incapacitated.  ACP often begins with an informal conversation with the patient (and trusted family members, if appropriate) to explore the patient's beliefs about illness, death, and health care interventions.

The ACP process is meant to promote patient empowerment by ensuring that patients receive care aligned with their expressed values.  However, patient participation in ACP remains low (<11% of patients) and occurs even less frequently among patients who belong to ethnic minorities (eg, Hispanic, Black, Asian).  Ethnic disparities in ACP initiation and completion may result from distrust of health care systems, cultural norms, misconceptions, and suboptimal physician communication.

This patient's statement indicates that she has a misconception about ACP—that she must "sign away" her life with legally binding documents.  It also indicates that she values ownership over her health care decisions—a value that is in fact supported by ACP.  Therefore, the physician should respond by explaining the ACP shared goal of patient empowerment (eg, of allowing her preferences to be shared) in simple, nonjudgmental terms.  Expressing this patient-centered goal can increase trust, acceptability, and likelihood of patient engagement in subsequent discussions.

(Choice A)  Given the patient's low probability of 12-month survival, realistic conversations about end-of-life care are important.  However, this statement does not clarify the purpose of ACP and focuses on the physician's opinion more than the patient's expressed values.

(Choice B)  The patient has not expressed fear, so this statement is less likely to engage her and may appear condescending.  Moreover, the statement does not offer clarity on the purpose and benefits of ACP.

(Choice C)  This statement alludes to only one potential outcome of ACP: participation of family members in patient care (eg, as surrogate decision makers).  The primary purpose of ACP is to identify and honor the patient's wishes;  it is premature to assume that the patient values or prefers family involvement.

(Choice E)  If the patient continues to decline engagement, her wishes should be respected.  However, the physician should first clarify potential misconceptions about ACP (eg, "sign away my life") and attempt to find common ground by highlighting the shared, patient-centered goal of ACP.

Educational objective:
Advance care planning (ACP) is the process of identifying a patient's health care goals in case of serious illness.  Patient participation in ACP is low, especially among ethnic minorities due to factors such as mistrust or suboptimal physician communication.  Physicians should engage patients in ACP by first explaining its primary purpose of patient empowerment (ie, identifying patient preferences that can subsequently guide medical decision-making).