Healthcare at End-of-life (EoL) in the older adult with a life-limiting illness is often crisis-driven, incongruent with patient and family preferences, and futile. Advance care planning (ACP) is an effective means of aligning EoL goals of care to values and preferences. ACP near EoL in the United States healthcare system is frequently under-utilized and fragmented. Without timely communication and education regarding EoL care options patients and their families are susceptible to spending their last days consumed by ineffective and potentially painful treatments. Alignment of goals of care with patient and family preferences has been shown to reduce crisis-driven care and caregiver distress supports appropriate resource utilization and reduces healthcare costs at EoL (Abernethy, 2013; Health Quality Ontario, 2014; Houben, 2014; MacKenzie, 2018; Nevis, 2014).

Date of publication

Spring 4-26-2020

Document Type

MSN Capstone Project



Persistent identifier



Master of Science in Nursing