Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Open Ended Questions to Promote Discussions for Advanced Care Planning

(Holley, 2007, p. 405)

Addressing goals of care when prognosis is uncertain

  • What are your most important hopes?
  • What concerns you most about your illness?
  • What is your quality of life like now?
  • Is it more important for you to live as long as possible, despite some suffering, or to live without suffering for a shorter length of time?
  • What are your biggest fears?
  • Given the severity of your illness, what is most important for you to achieve?
  • What do you understand about your illness?
  • How much do you want to know?

Advance-care planning and end-of-life issues


  • What makes life most worth living to you?
  • Are there circumstances in which you would find life not worth living?
  • Have you seen or been with someone who had a particularly good (or difficult) death?
  • What have been the worst and the best things about this illness for you?


  • If you are unable to speak for yourself in the future, who would be best able to represent your views and values? (substitute decision maker)
  • Have you given any thought to what kinds of treatment you would want, or not want, if you become unable to speak for yourself in the future? (advanced directive)
  • Have you considered circumstances in which you would want to stop dialysis?
  • Where would you like to be and who would you like to be there when you die?