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Document Type

DNP - University Access Only

Award Date


Degree Name

Doctor of Nursing Practice (DNP)


Graduate Nursing

First Advisor

Kay Foland


advance care planning, advance directive, community education


Advance Care Planning (ACP) is an essential aspect of healthcare for all adults. It is an ongoing and complex process that helps the individual plan for healthcare decisions in the event he or she are unable to speak for themselves. ACP often results in an advance directive (AD) which captures their wishes in writing. This process is a patient centered initiative that aims to maintain dignity and autonomy to patients by honoring their medical decisions throughout their lifetime. A review of literature gleaned three themes impacting ACP participation and AD completion rates. First, the impact of ACP and AD on healthcare utilization and patient experience. The second examines barriers to participating in ACP and completing an AD. Lastly, the use of evidence-based ACP programs to increase participation in ACP was reviewed. Identified gaps in the literature are a lack of initiatives for the general adult population, initiatives in rural areas of the country, and the effectiveness of state-wide ACP efforts. Recommendations for practice include those to support formal ACP which improves communication with the patient and his or her decision maker and increases the completion of AD documents. ACP initiatives can be provided in the outpatient or community settings.

Library of Congress Subject Headings

Advance directives (Medical care)
Community education.
Health education.
Rural population.

Number of Pages



South Dakota State University


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