Advance Care Planning Day 2021

April 16, 2021

When it comes to planning for your future health care, are you, your family and friends prepared? Have you had a conversation about what your end of life wishes are, or those of your loved ones?

Today is Advance Care Planning Day in Canada. One of our priorities is to ensure that every older Canadians living with frailty with a life limiting diagnosis or chronic illness has an advance care plan (ACP). Recently, CFN funded research on Advance Care Planning across multiple sectors including long-term care, primary care, and in hospital. The preliminary results from this research are summarized here:

Improving Serious Illness Conversations in the Hospital Setting:

  • Problem: Conversations between clinicians and hospitalized patients about serious illness are often too little, too late and not great and often lead to treatment that is inconsistent with patients’ values and goals. The Serious Illness Care Program (SICP) is an evidence-based intervention that uses a multi-faceted, system change approach to build clinician capacity for earlier, more frequent, and more person-centred conversations about the values and priorities of patients with serious illness.
  • Recommendation 1: Training clinicians to use the Serious Illness Conversation Guide is not enough on its own to change practice: system change (the entire SICP “package”) is also needed.
  • Recommendation 2: For teams who are implementing the SICP, implement and follow all the components in the SICP Implementation Roadmap.

Long-Term Care Needs Advance Care Planning:

  • Problem: There is a gap between the care that LTC residents prefer and that which they receive. ACP that extends beyond single medical decision-making can close the gap between preferred and received care, but it is not consistently implemented in LTC.
  • Recommendation 1: Train and encourage all staff, regardless of discipline, to participate in ACP discussions with residents.
  • Recommendation 2: Provide self-directed ACP materials with psychosocial content to improve ACP engagement in LTC.
  • Recommendation 3: Improve ACP uptake by creating a culture that supports compassionate care and communication amongst staff, residents and families.

Strategies to increase Advance Care Planning (ACP) Conversations in Primary Care:

  • Problem: What is needed to integrate ACP tools into primary care practice so that early and ongoing conversations occur with patients in primary care?
  1. Education and training for primary care clinicians can increase knowledge, comfort, and confidence in having ACP conversations.
  2. Evidence-based clinician and patient-facing tools can support good quality ACP conversations.
  3. Structure and processes integrated into primary care practice can overcome barriers and proactively engage patients in ongoing ACP conversations.

CFN Investigators: Sharon KaasalainenTamara Sussman, John You, Jessica Simon, Daniel Kobewka, Dev Jayaraman, Gloria Gutman


It is important to consider your own desires for end of life, and have these conversations with your loved ones. CFN is proud to support Speak Up Canada on ACP Day 2021,  you can visit, to learn more about advance care planning and find free downloadable resources such as workbooks, videos, wallet cards and conversation starters.