America is aging, with the estimated number of patients over the age of 65 to reach 72 million by 2030, approximately 20% of the population (Sade, 2012). This demographic shift characterized by an increasing elderly population has elevated the subject of death and dying to a crucial component of health care delivery. A study done by Silveira et al. (2010) demonstrated that 70% of individuals aged 60 and older were unable to participate in treatment decisions during their final days. However, most individuals in the United States have no advance directive.

The goal of this evidence-based practice intervention is to increase advance care planning by initiating discussion in primary practice. This will serve to honor the wishes of patients when acute events occur, based on their values and understanding of their diagnoses. With Medicare and Medicaid adding advance care planning to their fee schedule, discussion of advance care planning by a primary provider meets the needs of patients and is also a revenue source. A screening tool targeted to the primary care population will be created and advance care planning offered by the provider. A list of discussion prompts is provided for providers to utilize with their patients. By participating in advance care planning, patients with have more autonomy over their care towards the end of their lives, increasing their dignity and decreasing emotional distress for patients and family.

Advance care planning should be discussed in the primary setting before acute events occur. Patients should be targeted at the age of 65 or with diagnosis of moderate to severe disease. When possible, family or surrogates should be included in this process. Finally, advance care planning should be discussed on an ongoing basis to reflect the changing priorities of the patient.

Date of publication

Fall 12-9-2021

Document Type

MSN Capstone Project



Persistent identifier



Master of Science in Nursing Administration