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advance care planning, advance directive, simulation, Voicing My Choices, young adults



  1. Smith, Sharon L. DNP


The process of advance care planning (ACP) is shown to improve quality of life at the end of life by increasing communication, social support, autonomy, and emotional well-being and by decreasing stress, anxiety, and depression. However, approaching the topic of ACP is challenging, and there is often discomfort on the part of the clinician, as well as the patient and family. Issues such as fear of removing hope, lack of training, and timing are described in the literature as barriers to discussions about end of life. Conversations about future health are not easy and are often avoided by both health care providers and families. They are even less likely to occur if the patient is not an adult. The literature on ACP in young adults has increased in recent years and shows that this communication does not result in distress or negative effects on psychological well-being and is helpful for patients and caregivers. The purpose of this evidence-based project was to use an advance directive document as a guide to initiate communication about ACP for young adults with high-risk cancer in a simulated clinical setting. A pretest/posttest nonexperimental design was used to describe nurse provider confidence and attitudes toward ACP in young adults, as well as satisfaction with the use of Voicing My Choices to introduce ACP within the simulated experience. Eighteen nurse providers were recruited from a convenience sample of practicing pediatric nurses and nurse practitioners from a large metropolitan teaching hospital. Each measure of self-confidence in ACP significantly increased after the simulation, including comfort in ability to initiate ACP in the practice setting (t = -4.01, P < .0009), confidence in ability to discuss ACP (t = -2.49, P < .02), confidence in ability to discuss ACP with patients younger than 18 years (t = -3.42, P < .003), and an acknowledgement that they possess the skills needed to have an ACP discussion with their patients (t = 0.002, P < .002). There was an overwhelmingly positive response to this simulation activity. The participants felt that the simulation should be held routinely and that ACP should be a regular part of conversations with patients. Advance care planning is important and, too frequently, a missing step in the care of young adults with life-limiting conditions. There is evidence to support the recommendation that clinicians routinely provide ACP to young adults. However, few nurse providers have training or experience in having these difficult conversations. Offering a simulated learning environment enables the learner to develop competence and confidence in communication skills required for difficult conversations such as ACP in a safe environment. In this project, most nurses had no previous training in ACP. After a 45-minute simulation exercise, these nurses expressed significant increases in self-confidence and skills not only to discuss ACP but also to initiate the conversation. In addition, nurse providers felt that it was beneficial to use an ACP tool such as Voicing My Choices as a guide to structure the conversation.