advance care planning, Age-Friendly Health System, older adults, oncology, what matters most



  1. Vonnes, Cassandra DNP, GNP-BC, APRN, AOCNP, CPHQ, FAHA
  2. Parrish, Lauren BSN, RN
  3. El-Rady, Rosalie APRN, AOCNP
  4. Patterson, Dorothy RN, CHPN
  5. Mason, Tina M. PhD, APRN, AOCN, AOCNS, FCNS


Approximately 1 in 3 adults have some type of advance directive. Advance care planning (ACP) is associated with greater use of supportive care services and decreased patient and family stress. Despite this, organizations continue to have difficulty in implementing effective programs for increasing ACP. Increasing knowledge and comfort of the health care team with end-of-life discussions and ACP is essential. Educational efforts should focus on decreasing known barriers to ACP discussions such as discomfort, unclear role, lack of experience, and limited education. Role playing and case discussions taught by geriatric resources nurses can help increase staff knowledge and comfort regarding ACP. Role playing allows staff to think about their own mortality and what will happen in various situations if ACP is not complete. Team members find that once they have completed their own ACP, they are more comfortable discussing ACP with patients and caregivers. Nurses should collaborate with social workers and chaplains for ACP education and discussing what matters most to them. Patients are encouraged to make sure that they provide advance directives to their health care providers. This article shares an interprofessional team approach to improving processes for ACP as a component of "what matters most" to older adults with cancer.