Help Patients Define What Matters Most: Advance Care Planning Made Simple

Advance care planning (ACP) is one of the most meaningful ways clinicians can align care with what matters most to patients. By identifying the right decision-maker and documenting patient preferences, physicians can help ensure care teams deliver treatment that reflects the patient’s goals—while avoiding unnecessary interventions.

Why Advance Care Planning Matters

“Understanding what matters most to a patient helps determine what treatments make sense within the framework of their illness,” says Susan Nelson, MD, Medical Director of Palliative Medicine for Ochsner Health. “When people are near end of life, most don’t want to spend their last month in an ICU unless the situation is clearly reversible.”

Advance care planning is also a key component of the Centers for Medicare & Medicaid Services (CMS) Age-Friendly Health Systems framework, which focuses on the “4Ms”:

• Mentation – mood and memory
• Mobility – maintaining safe movement
• Medications – ensuring medications are appropriate
• What Matters Most – aligning care with patient goals

ACP directly supports the “What Matters Most” pillar, helping clinicians deliver care that aligns with patient priorities.

Streamlined Documentation in Epic

To make documenting these conversations easier, clinicians on Ochsner’s instance of Epic can use the .ACP SmartPhrase. Typing .ACP into a note links directly to the advance care planning module, where preferences and directives can be stored and accessed by care teams across the system. This ensures that if a patient is admitted or seen in the emergency department, their previously discussed goals of care are readily available.

“The goal is simple,” says Dr. Nelson. “Help patients identify what matters most to them—and make sure that information is documented so every member of the care team can see it.”

For providers not on Ochsner’s instance of Epic, Ochsner’s website has an advance care planning resources page where you or your patients can get information and download printable ACP forms to use. Visit ochsner.org/services/palliative-care/advance-directives.

Tools to Support Patient Conversations

Ochsner provides patients with access to MyDirectives, an online advance care planning platform available through MyChart and on Ochsner.org. This tool guides patients through the Five Wishes document, which addresses:

• Who should make medical decisions if they cannot
• What kinds of medical treatment they want and don’t want
• How comfortable they want to be
• How they want to be treated
• What they want loved ones to know

Completed documents are stored electronically and feed directly into Epic, making them accessible to care teams.

Start the Conversation Today

While advance care planning is especially important for older adults and patients with serious illness, these conversations benefit patients at every stage of life. By starting the conversation today and documenting it in Epic, clinicians can ensure patients receive care that aligns with their goals—when it matters most.