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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Advance Care Planning

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

A=Advance Care Planning (ACP)

Related Issues:

Advance Directive, DNR, Health care proxy, Living will, Medical power of attorney, Medical Orders for Life Sustaining Treatments (MOLST)

Why Advance Care Planning is Important:

  • The Patient Self Determination Act of 1990 established that healthcare facilities were mandated to communicate to patients their right to make decisions about their care
  • Advance directives document a patients’ wishes with respect to life sustaining treatment, their selection of a surrogate decision maker or both
  • Promotes patient autonomy, and increases the likelihood that healthcare decisions will match the patients personal values and choices
  • Eases the burden on families and health care providers when the patient is unable to make decisions for themselves
  • A cancer diagnosis in the older adult may increase awareness of the need for an Advance Care Plan
  • It is optimal to address Advance Care Planning prior to the initiation of treatment (chemotherapy, radiation, surgery)

Older adults are at increased risk of:

  • Cognitive & functional decline
  • Limited health literacy and/or functional health literacy (ability to read & comprehend prescriptions bottles, appointments, etc.)
  • Having cultural, religious, spiritual issues misunderstood or not respected
  • Not having discussed end of life care with their family or caregivers
  • Being socially isolated
  • Absent or abusive support systems


Screening Questions

  • Do you have a completed health care proxy form or living will that reflects your current wishes?
  • Have you discussed you wishes with your health care agent?
  • Do you know who you would choose to make decision about your medical treatment if you were unable to make them for yourself?

A=Advance Care Planning (ACP)

Nursing Intervention:

  • Identify barriers to advance care planning with patient and family
  • Provide written and verbal information to patient and family
  • Maintain current knowledge of your institutions policies and your states regulations related to Advance Care Planning: (i.e. New York)
  • New York State recognizes three types of advance directives:  New York State Healthcare Proxy, Living will and Do Not Resuscitate Order (DNR), MOLST Form
  • “Planning your healthcare in advance”, a 31 page guide with advance directive forms
  • Clarify the patient’s understanding of their illness and treatment options
  • Determine/recognize/understand the patients values, beliefs and goals of care
  • Provide written and verbal information about health care decision making to the patient and family
  • Explore resuscitation issues with the patient and their health care designee & facilitate discussion with the health care team
  • Facilitate completion of appropriate forms with provision to the appropriate care providers


Cohen, A., Nirenberg, A. (2011). Current Practices in Advance Care Planning: Implications for Oncology Nurses. Clinical Journal of Oncology Nursing 15(5), 547-553.
New York State Department of Health. (2011). Palliative Care Information Act. Retrieved from