Publication Date

Spring 2018

Degree Type

Doctoral Project

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Sylvia Miller

Second Advisor

Diep Pham

Third Advisor

Rachel Law


Elderly, Advanced care planning, Primary care


The purpose of the project was to examine if the identification of readiness for an advance care planning (ACP) discussion of elderly participants would enhance the outcomes of participants' satisfaction, improve the likelihood of having an ACP discussion and increase the completion rates of an advance directive (AD) document after an office visit.

Forty-four elderly participants, who met the selection criteria, were recruited from a primary clinic in Northern California from October 1, 2017 to December 31, 2017 (Female, n =28). All participants were randomly assigned to either an intervention group (n= 22) or a control group (n =22). Their age ranged from 65 to 89 years (M = 72.89; SD = 7 .31). A pre- and a post-visit self-administrated questionnaire were used for data collection with a follow-up phone call made to the participants post-visit.

Project findings indicated that the intervention participants who were ready for an ACP discussion were more likely to have an ACP discussion and complete an AD document than the control participants post-visit (p <.05). Although there were significant differences of some demographic variables between groups to confound the ACP outcomes, findings of this project were clinically significant.

In conclusion, the investigator advised that primary care providers should initiate the ACP discussion, document the conversation and complete an AD document when the elderly patients clearly state that they are ready for an ACP discussion.


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