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Advance Care Planning

5th Edition
October, 2015

The Canadian Stroke Best Practice Recommendations for Acute Inpatient Stroke Care, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Advance Care Planning and all other sections of the Acute Inpatient Stroke Care recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://wso.sagepub.com/content/11/2/239.full.pdf+html

For the French version of these recommendations, open the appendix at this link : http://wso.sagepub.com/content/11/2/239/suppl/DC1

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.



Advance care planning is a process through which a patient in consultation with health care providers and family members make decisions regarding their health care, should they become incapable of participating in decision making. Often in patients with stroke, the direction of these decisions is unclear for the family when the patient is unable to participate in decision-making. Advanced care planning is an important educational aspect of any patient encounter when a serious or chronic condition is involved, where the risks of a recurrent event are increased, such as with stroke.




System Implications

  • Protocols for advanced care planning to elicit patient and family goals for care preferences, and ensure these are documented and communicated to decision makers and healthcare team members.
  • Information on advanced care planning and linkages to local stroke support organizations and their services should be available for staff to share with patients and families.
  • Communication training for physicians, nurses, and allied health professionals that addresses supporting patients and their families through advanced care planning.





Performance Measures

  1. Percentage of stroke patients who have been approached to participate in advance care planning and/or who have a documented conversation with a healthcare provider about resuscitation, hydration, and/or feeding preferences.
  2. Percentage of stroke patients who identify a substitute decision-maker.
  3. Percentage of stroke patients who complete a personal or advance care directive documented on their chart.
  4. Percentage of patients with advanced care plans whose actual care was consistent with the care defined in their advanced care plan.

Measurement Notes

  • Documentation for the advance care plan measures may appear in consult notes, nursing notes, or physician notes.
  • A copy of the advanced care plan may be included in the patient’s chart.
  • Data quality may be an issue with some of these performance measures. Improved documentation should be promoted among healthcare professionals.
  • Patient and family experience surveys should be in place to monitor care quality with end-of life situations.





Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information





Summary of the Evidence, Evidence Tables and References

Evidence Table and Reference List

Advance care planning is a process through which a patient in consultation with health care providers and family members make decisions regarding their health care, should they become incapable of participating in decision making. Elements of advance care planning include the patients’ prognosis, treatment options, goals of care, and the identification and documentation of end-of-life wishes (Detering et al. 2010). Unfortunately, there is some evidence that the adherence with stated and documented end-of-life preferences may be poor. In a prospective study (Heyland et al. 2013) included 278 elderly patients admitted to 12 hospitals, who were at high risk of dying in the next 6 months and their family members (n=225). Patients and family members were interviewed 2-5 days following admissions related to advanced pulmonary, cardiac, or liver disease, and metastatic cancer. When the medical records were reviewed immediately following the interview, among the 199 patients who had expressed end-of-life care preferences and had a documented goals-of-care order, there was crude agreement between the documented preferences and the patient’s stated preferences in only 30.2% of cases. Of the 276 patients who had expressed a preference for care, 77 (27.9%) did not have a written order in the record stating the goal of care. Of these, only 12 (15.6%) preferred aggressive medical management, including resuscitation. The area of poorest agreement was between the stated (28.1%) and documented (4.5%) preference for comfort measures.

Although no stroke-specific studies have been published that examine the effectiveness of advance care planning, several exists that include patients with mixed diagnoses. Evidence suggests that interventions aimed at increasing advance care planning have been successful in significantly increasing the likelihood that end-of-life wishes are known and respected (Detering et al., 2010; Grimaldo et al., 2001; Kirchhoff et al., 2012). In a study of 309 patients’ admitted to internal medicine, cardiology, or respiratory medicine, Detering et al. (2010) randomized patients to receive formal advance care planning from a trained facilitator or usual care. The intervention was based on the Respecting Patient Choices model, which involves reflection on goals, values, and beliefs, documentation of future health care wishes, and appointment of a surrogate decision maker. Of those who died, end-of life wishes were significantly more likely to be known and respected for participants in the intervention group compared with those in the control group (86% vs. 30%, p<0.01). Following the death of a loved one, family members of those in the intervention group reported significantly less anxiety and depression and more satisfaction with the quality of their relatives death, compared to control group family members. Kirchhoff et al. (2012) randomized 313 patients (and their surrogate decision makers) with congestive heart failure or end-stage renal disease who were expected to experience serious complication or death within 2 years, to receive a patient-centered advance care planning intervention or usual care. The intervention was composed of a 60 to 90 minute interview with a trained facilitator to discuss disease-specific end-of-life care issues and options and documentation of treatment preferences. 110 patients died within the study period, of which 26% required a surrogate decision maker at the end-of-life. Only a single patient in the intervention group and 3 in the control group received end-of-life care that was contrary to their wishes for reasons other than medical futility. With respect to resuscitation preferences, non-significantly fewer patients in the intervention group received care that was contrary to their wishes (1/62 vs. 6/48).