| Step | Purpose | Question/comment |
| Permission | Invites the patient to discuss their current condition and desires regarding future medical care | "Would you like to talk about what might happen in the future, and how we could make sure your wishes are followed?" |
| Preference | Allows patient to determine how involved they are in planning, and whether they want others involved | "Would you like to talk about this by yourself, or are there others you would like to join us?" |
| Establish the baseline | To determine what the patient's understanding is regarding their medical situation at the present time | "What is your understanding about your medical situation?" "What have your doctors told you?" |
| Provide information | To provide clear information about the choices that may be faced in the future, individualized to the patient's own current medical condition | For a patient with recurrent cancer, for example: "Because your cancer came back, it is not curable. You will be living with this disease for the rest of your life, like a chronic disease." |
| Introduce dilemmas at hand | To determine if the patient has thought about the medical care they would like to receive in the future | "Has someone close to you had to face end-of-life decisions, like deciding about withdrawing a ventilator or going on hospice? What would you have wanted in that situation?" |
| Explore values and beliefs | To help the patient define what it means to "live well" | "What is most important to you in life?" "What are your main worries about your situation?" "When you think about your future, what do you hope for?" |
| Elicit advance care planning preferences | To guide the patient to state specific preferences about advance care planning, including cardiopulmonary resuscitation, life-prolonging treatment, and inpatient hospitalization | "If you were to stop breathing, would you want to be on a machine that breathes for you?" Note: If the patient is interested in a trial of life support, the clinician should ask them to specify the parameters of the trial (how long? criteria to decide when to stop treatment). |
| Identify a surrogate decision-maker | To specifically name someone who will carry out their wishes in the case they are unable to in the future | "If you became unable to tell your clinicians what kind of care they should provide you, who would you want to make medical decisions for you?" Note: If the patient names multiple persons, aim to establish a primary surrogate. |
| Educate about the role of a surrogate | To ensure understanding on how the surrogate decision-maker would function in the future | "If you became unable to participate in discussions about your care, your surrogate would be called in to tell us what should be done." |
| Encourage dissemination among family | To ensure that the advance care planning decisions of the patient are known to their loved ones, and specifically, to the surrogate(s) | "It would be important to let your family know of your wishes and desires for the future. This includes letting everyone know who you have chosen as your surrogate decision-maker." |
| Document | Encourages the patient to complete advance care planning forms, which will increase the chances their wishes are followed in the future | "These are important decisions that will impact your care in the future. We should make sure to get them in writing." |
| Review | Review of these plans on a regular basis ensures that advance care planning decisions accurately reflect their decisions | "Would you like to revisit your advance care plans? I just want to make sure they still reflect your wishes today, compared with when we did it the last time." |
