Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Elements of Advance Care Planning
·         clarifying the patient’sunderstanding of their illness;
·         elucidating the situation and treatment options;
·         understandingthe patient’s values, priorities and goals of care;
·         identifying and documenting the patient’s wishes; and
·         nominating a substitute decision-maker for a time when the patient may not be able to make decisions independently (Romer & Hammes, 2004).