Advance care planning in primary & long term care

“We became much more aware of what we want, how to approach the subject, and what can be done.”


Advance care planning (ACP) is a process that supports people in understanding and sharing their personal values, life goals and preferences related to future medical care. The goal of ACP is to prepare people, and their substitute decision-maker(s), for future “in-the-moment” treatment decisions so that people get medical care that is consistent with their values, goals and preferences during serious illness. ACP can improve the patient experience, align treatment with patient preferences, avoid unwanted and costly invasive treatments near end-of-life (EOL) and improve psychological outcomes for family members during bereavement.

For this project, our experienced team of clinicians and researchers focused on increasing uptake, impact and access to ACP for Canadians older Canadians living with frailty across the primary care, long-term care (LTC) and hospital settings. We achieved this by tailoring, implementing and evaluating a multi-faceted suite of ACP tools in these care settings, while paying particular attention to the needs of marginalized groups.

Michelle Howard, PhD, MSc is an Assistant Professor in the Department of Family Medicine and an Associate Member of the Department of Clinical Epidemiology and Biostatics at McMaster University. Dr. Howard completed her doctorate at McMaster, and her MSc at the University of Toronto. Her research interests include evaluating and improving primary care models and understanding the mechanisms and impacts of interprofessional care in primary care practices.

Sharon Kaasalainen, RN, BScN, MSc, PhD is a Professor and the Gladys Sharpe Chair in Nursing in the School of Nursing at McMaster University. Dr. Kaasalainen is also an Associate member of the Department of Family Medicine at McMaster University. Dr. Kaasalainen’s research program is focused on improving the quality of life for people living in long term care homes with a particular focus on implementing a palliative approach in dementia care. She has received research funding from CIHR, SSHRC, and the Ministry of Health and Long Term Care; both as a principal and co-investigator with the primary focus on improving quality of care for LTC residents and their family.

Tamara Sussman, MSW, PhD is an Associate Professor in the School of Social Work at McGill University. She obtained her undergraduate and master’s degrees at McGill University, and a PhD in Social Work at the University of Toronto, followed by a Post-Doctoral Fellowship at the Murray Alzheimer Research and Education Program at the University of Waterloo.  Dr. Sussman’s  program of research focuses on how health services and systems impact older adults and their family members, including spousal careers’ experiences with home care; older adults’ and family members’ experiences with the transition into long-term care; barriers and facilitators to the delivery of effective interventions for depressed older adults and their care partners; and most recently the needs and experiences of more marginalized older adults in long-term care such as previously homeless older adults and older adults identifying as gay, lesbian, bisexual and transgender (LGBT).