Date of Award

Spring 5-27-2023

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Lisa Sheehan, DNP


Advance Care Planning (ACP) is an ongoing discussion about medical decision making between a provider, patient, and support person. ACP can also include legal documentation in the form of an advance directive (AD). Nationally, only 36.7% of adults complete any form of AD for end-of-life care. Recently, ACP has become an important quality metric that many organizations are prioritizing. The purpose of this evidence-based project is to improve ACP readiness, self-efficacy, and documentation among patients at an internal medicine clinic using the PREPARE program and referral to an ACP group meeting. PREPARE for Your Care is an online program aimed at preparing diverse populations for medical decision making. Ten participants were recruited for this project and were given a validated preintervention survey assessing self-efficacy and readiness. Interventions included brief education using PREPARE documents and referral to an ACP group meeting. Post surveys were to be completed after ACP group meeting attendance; however, group meetings were abruptly discontinued during project implementation. Five participants responded to post surveys based on the intervention of PREPARE education alone. When comparing pre and post data, 40% of participants self-efficacy scores increased, 40% decreased, and one participant’s scores were unchanged. Eighty percent had decreased readiness scores while one participant had increased readiness scores. A comprehensive chart review showed no increase in ADs on file postintervention. Overall, self-efficacy, readiness, and AD completion were not improved with PREPARE education alone. The project outcomes suggest that ACP group meetings be reinstated to improve ACP self-efficacy, readiness, and AD completion.

Keywords: Advance care planning, advance directive, self-efficacy, readiness