advance care planning, advance directive, interdisciplinary team, palliative care, quality improvement



  1. Fink, Regina M. PhD, APRN, AOCN, CHPN, FAAN
  2. Somes, Elizabeth MD
  3. Brackett, Hareklia MS, RN, CNS, ACHPN
  4. Shanbhag, Prajakta MPH
  5. Anderson, Ashley N. BSN, RN
  6. Lum, Hillary D. MD, PhD


Despite the established benefit of advance care planning (ACP), achieving and sustaining high rates of ACP completion continue to be a challenge in many health care settings. A palliative care champions committee has targeted improving the ACP process through quality improvement initiatives at an academic medical center. To understand the impact of multiyear efforts to improve ACP, surveys of registered nurses, care coordinators, and medical assistants from inpatient and outpatient settings were conducted in 2013 and 2017 to explore comfort level with ACP, barriers preventing completion of ACP in daily practice, and suggestions for overcoming these barriers. The findings suggest strategies to further integrate ACP through interdisciplinary teams, including outpatient staff education, inpatient and outpatient quality improvement initiatives, and dedicated staff for ACP.