The Respecting Choices ACP evidence-based program can be successfully replicated in diverse communities and cultures. The four key elements of a successful ACP microsystem—designing systems, training and education of ACP facilitators, community engagement strategies, and ongoing quality improvement—are effective principles for customizing an effective ACP program. These principles alone, however, will not yield success. Creating and sustaining a comprehensive ACP program as described requires significant commitment of leadership, human and financial resources, and practical plans for ongoing dissemination. Effective leaders integrate ACP into the strategic vision of the organization, building the infrastructure for long-term success.

Organizational leaders who make this commitment face significant challenges. Those who are successful share a common belief that building an effective ACP program is simply the right thing to do and are willing to invest resources to remove barriers to implementation. Leaders understand that patients and families find ACP highly satisfying and crucial to ensuring that they receive care consistent with their goals, values, and preferences. Successful outcomes are reflected in the stories of those whose lives are touched by ACP interventions.

In the words of one health care agent who participated in an ACP planning discussion with his father, and subsequently used this information to make health care decisions when his father was incapacitated by a severe stroke,

The conversation was eye-opening for me. With a third party present, I learned things I never knew about my dad . . . . During the conversation with the facilitator, she asked a lot of questions . . . . She stuck to the facts . . . . At no point was there any pressure to choose one option or another. . . . The choice was
his; the facilitation just provided the road map. In the end . . . the decision was not up to us; our father made it very clear what he wanted in advance. (Loomis, 2012, p. 154)

These stories are now common in the La Crosse community, and “If I only knew” situations are rare. The comprehensive Respecting Choices approach to creating a sustainable ACP program is worth the investment. This approach has demonstrated evidence that the ultimate goals of ACP are achievable: to know and honor individuals' informed health care decisions.


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