Date of Award

Spring 5-22-2021

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Caroline Etland PhD, RN, AOCN, ACHPN

Second Advisor

Glenn Panzer, MD


Background: Advance care planning (ACP) has always been a priority in healthcare, and even more crucial during the COVID-19 pandemic. It has been extremely challenging for ACP to occur in the skilled nursing facility (SNF) population once social distancing restrictions were put in place to protect residents and staff.

Purpose: The purpose of this evidence-based project was to assess the effectiveness of ACP via teleconferencing with skilled nursing facility (SNF) residents in the hope of increasing completion of high-quality Physician’s Orders for Life-Sustaining Treatment (POLST) forms.

Methods: The San Diego Coalition for Compassionate Care developed an ACP community outreach program in which an Advance Care Planner and Nurse Practitioner (NP) student conducted teleconferences with SNF residents in participating facilities to offer advance care planning conversations.

Results: At the end of a 6-month measurement period, quantitative and qualitative data was evaluated. There were a total of 10 advance care planning conversations that were conducted with two of the conversations were held in Spanish. Among the 10 conversations, seven of the 10 residents chose to complete a POLST form resulting in a 70% completion rate. Qualitative feedback responses were recorded and indicated high satisfaction with the process.

Conclusion: This project demonstrated effective discussions can take place via teleconferencing on sensitive topics such as wishes for life-sustaining treatment, even with non-English speaking residents. These findings could have broad implications for future ACP conversations, increasing the quality and volume of POLST forms that are completed for those most at risk of unwanted treatment and training clinicians to conduct ACP conversations early in their career.