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Advance Care Planning discussed and documented advance care plan or surrogate decision maker documented in the medical record (DEM) (GER, Pall Cr)

CPT4 code

Name of the Procedure:

Advance Care Planning
Common Names: ACP, Advance Directive Planning
Technical or Medical Terms: Advance Care Plan, Surrogate Decision Maker Documentation, ACP Documentation, DEM, GER, Pall Cr


Advance Care Planning is the process of discussing and documenting your future healthcare preferences, which may include naming a surrogate decision maker to make choices on your behalf if you become unable to do so.


Medical Condition or Problem: Advance Care Planning addresses the need for individuals to have their medical care preferences honored if they become incapacitated or are unable to communicate. Goals/Expected Outcomes:

  • Ensure medical treatments align with the patient's values and wishes
  • Provide clarity and guidance to healthcare providers and family members
  • Reduce stress and uncertainty in critical situations


  • Chronic or serious illness
  • Advanced age
  • High-risk surgical or medical procedures
  • Any adult wanting to ensure their health care preferences are known and respected


  • Reflect on personal values, treatment preferences, and any specific healthcare choices
  • Discuss options with family members and healthcare providers
  • Complete necessary forms and documents

Procedure Description

  1. Discussion: An in-depth conversation between the patient, family members, and healthcare providers about the patient’s values, treatment preferences, and potential healthcare scenarios.
  2. Documentation: Formalizing decisions by filling out advance care directive forms and appointing a surrogate decision maker.
  3. Storage: Ensuring that the completed documents are part of the medical record and accessible to healthcare providers.

Tools/Equipment: Advance directive forms, healthcare proxy forms
Anesthesia or Sedation: Not applicable


The length of the discussion may vary, typically ranging from 1 to 2 hours, depending on the complexity and depth of conversation.


  • Hospital
  • Outpatient clinic
  • Home setting
  • Long-term care facilities


  • Primary care physicians
  • Nurses
  • Social workers
  • Palliative care specialists, if applicable

Risks and Complications

Common Risks: Emotional distress for the patient and family during discussions Rare Risks: Miscommunication or misinterpretation of the patient's wishes


  • Clear documentation of the patient's healthcare preferences
  • Empowerment for patients, reducing anxiety about future medical care
  • Enhanced communication between patients, families, and healthcare providers


Post-Procedure Care: Regular review and updates of the advance care plan, especially after a major medical change or life event. Expected Recovery Time: Not applicable


  • Informal discussions without formal documentation (less reliable)
  • No planning, with decisions deferred to medical personnel at the time of need (may not align with patient’s desires)

Pros and Cons of Alternatives:

  • Informal discussions may not be honored legally
  • Lack of planning can lead to decisions that contradict patient’s wishes

Patient Experience

During the Procedure: Patients should expect to discuss their values, preferences, and beliefs about medical treatment. Emotional support may be necessary as the topic can be sensitive. After the Procedure: Peace of mind knowing their wishes are documented and shared with key individuals. Potential relief for families from having clear guidance during difficult decisions.

Pain Management and Comfort Measures: Not applicable.

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