The typical approach to ADs has focused on completion of a standard, legalistic form and in compliance with the PSDA or other regulatory guidelines. This focus has resulted in a series of yes and no questions on admission (e.g., “Do you have an AD?” and “Would you like more information?”) and, unfortunately, created impersonal and ineffective practices regarding information presented to patients and the quality of their interactions with health care providers. “Just get it done” is often the mantra for busy professionals or others who do not feel comfortable having—or do not feel prepared to have—ACP discussions. More importantly, this approach ignores the need to address the multiple barriers to engaging individuals and their families in the planning process. While many Americans are knowledgeable about the importance of ADs, they remain unmotivated to participate due to personal beliefs, misunderstandings, perceptions of how difficult the activity may be, or the belief that it can wait for a future time (Eiser & Weiss, 2001; Sahm, Will, & Hommel, 2005; Schickedanz et al., 2009). Health care providers also remain uncomfortable and unskilled at having ACP discussions (Christakis, 1999; Scherer, Jezewski, Graves, Wu, & Bu, 2006; Yedidia, 2007). The perceived lack of time and reimbursement for ACP activities are further impediments to provider-initiated quality conversations (Legare, Ratte, Gravel, & Graham, 2008; Weiner & Roth, 2006).

The Respecting Choices approach is different. It assumes that conversations are the key to successful planning, that time and resources will be needed, and that health care providers will require communication skills training. Several characteristics of the Respecting Choices approach to ACP help overcome the barriers to participation in planning discussions, improve the decision-making process, and produce a more effective written plan.


The success of any program is measured by whether it achieves its stated goals. When the goals of ACP are narrowly defined (e.g., increase the incidence of completion of ADs), then only narrowly defined strategies will be designed to meet this goal. Although it is desirable for the planning process to result in the completion of a written plan that is consistent with statutory and regulatory requirements, the Respecting Choices approach has more comprehensive goals:

1. Assist individuals in making informed health care decisions.

2. Assist in the selection and preparation of a qualified health care proxy.

3. Honor informed decisions. To gauge the achievement of these far-reaching ACP goals, one must do more than count the number of ADs completed. To accomplish more specific goals, communication strategies are designed to provide planning assistance to individuals and their families at multiple encounters, to include chosen health care agents in discussions, and to assist agents in understanding their loved ones' preferences. In addition, systems are created to ensure that plans are available and actionable across the continuum of care to achieve the goal of honoring individuals' informed health care decisions.


The initial development of the Respecting Choices program was prompted by multiple stories of patients whose goals and values for future health care were unknown. These stories included individuals who could no longer communicate their preferences for future medical care due to sudden injury or complications from advanced illness. Families, physicians, and other health care providers felt the impact of this void on bedside decision making. Families were stressed morally, ethically, and physically with the uncertainty of making decisions for a loved one. Personal narratives provided the framework for designing an ACP system that has kept the individual's perspective front and center.

Person-centered interviewing skills form the core of Respecting Choices ACP facilitation. These skills are the vehicle through which to explore the individual's experiences, fears, religious or cultural beliefs and goals for living well, among other variables. This assessment forms the basis for crafting an individualized approach to planning.

Person-centered ACP is focused on engagement and not merely education. Educational efforts to increase understanding of the importance of ADs have been successful yet have not had a significant impact on participation in the ACP process. In a 2005 Pew Research Center survey on ADs, 84% of respondents were aware of the importance of their rights to make life-sustaining treatment decisions ( detail.aspx?id=23572). The missing link for many individuals is motivation. Consistent with Prochaska's stages of change model, motivational strategies assist in moving individuals from precontemplation (no interest in taking action) to action (participation and making changes) (Prochaska & Velicer, 1997).

Respecting Choices uses a variety of strategies to motivate individuals to participate in planning and helping them understand the components of a well-designed planning process.

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