Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Elizabeth Tovar

Clinical Mentor

Elise Puffer

Committee Member

Dr. Michelle Pendleton


Background: Advance care planning is the process of making decisions about the healthcare one wishes to receive should they become unable to make decisions for themselves, including the development of advance directives and designation of health care surrogates. Advance care planning is universally supported by governing bodies and professional organizations; however, less than one-third of Americans have an advance directive or designated health care surrogate.

Purpose: The purpose of this project was to assess primary care provider attitudes and knowledge of advance care planning and to increase screening for and documentation of advance directives and/or health care surrogates in patients age 65 years and older in a primary care setting.

Methods: This study was a quasi-experimental one group pre-test posttest design to assess the effect of provider education on provider screening and documentation rates of advance directives and/or health care surrogates in patients age 65 years and older in the primary care setting. Provider attitudes and knowledge of advance care planning were assessed through an attitudes survey and knowledge questionnaire.

Results: Pre-intervention screening, or documentation of either a negative or affirmative response to having an advance directive, was relatively high (79.9%). Documentation, or scanning an advance directive, including living will or power of attorney, into the media portion of the electronic medical record or documentation of the name of a designated health care surrogate in the electronic medical record, was low (3.9%). Although improvements in screening (84.5%) and documentation (5.6%) were seen post intervention, they were not statistically significant (p=0.41; p=0.56). Providers reported an overall positive attitude toward advance care planning as well as a lack of training and confidence in advance care planning. Provider knowledge of advance care planning improved from pre-intervention (70.5%) to post intervention (83.8%), although the improvement was not statistically significant (p=0.3). Providers identified inclusion in work flow, patient initiation of the topic, having available resources, and organizational support to be facilitators of advance care planning, and lack of provider comfort with the topic, inadequate time for discussion, lack of available resources, and lack of interest from the patient to be barriers to advance care planning.

Conclusion: This study successfully assessed provider attitudes and knowledge of advance care planning, identified specific facilitators and barriers to the process, and identified a high screening rate for advance directives in patients age 65 years and older. The study also highlighted the severe deficiency in documentation of advance directives and health care surrogates in the electronic medical record despite relatively high screening rates. Continued efforts should be made to ensure our primary care patients have their wishes documented in their record in order to improve quality and satisfaction with end-of-life care, decrease unnecessary hospitalizations and interventions at the end-of-life, and decrease cost to the health care system.