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Advance care plan or similar legal document present in the medical record (COA)

CPT4 code

Name of the Procedure:

Advance Care Plan, also known as Advance Directive, Living Will, or Durable Power of Attorney for Healthcare


An Advance Care Plan is a legal document that outlines a person's wishes regarding medical treatment in situations where they are unable to make decisions for themselves. It may include instructions about end-of-life care, resuscitation preferences, and the appointment of a healthcare proxy.


The Advance Care Plan addresses situations where an individual is incapacitated and unable to communicate their medical preferences. The primary goal is to ensure that the patient's healthcare wishes are known and respected, thereby guiding healthcare providers and loved ones in making informed decisions.


  • Chronic illnesses like dementia, cancer, or heart disease.
  • Advanced age or progressive decline in health.
  • Situations where a person may become unable to communicate their healthcare preferences.


  • Discuss your wishes with family members and healthcare providers.
  • Appoint a healthcare proxy or durable power of attorney.
  • Complete any required forms or legal documents, and have them witnessed or notarized as needed.

Procedure Description

  1. Discuss Wishes: The patient discusses their medical treatment preferences and goals with their loved ones and healthcare providers.
  2. Document Creation: The patient completes an Advance Directive or Living Will, specifying their preferences for treatment and care.
  3. Healthcare Proxy: If a healthcare proxy is appointed, the patient designates someone they trust to make healthcare decisions on their behalf.
  4. Legal Formalities: The document is signed, and in some cases, notarized. Copies are distributed to the patient's healthcare proxy, family members, and medical providers.
  5. Review and Update: The document should be reviewed and updated periodically, especially after significant health changes.


The initial discussion and document preparation may take several hours. Periodic reviews may take 30 minutes to an hour.


Primarily completed at home, healthcare provider's office, or with a legal professional. It does not require a hospital or surgical center setting.


  • Patient
  • Family members or loved ones
  • Healthcare provider (doctor, nurse)
  • Legal professional (optional for notarization)

Risks and Complications

  • Miscommunication or misunderstanding of patient's wishes.
  • Legal disputes if the document is not clearly or properly completed.


  • Ensures patient's medical treatment preferences are known and respected.
  • Reduces stress and uncertainty for family members and healthcare providers.
  • Provides peace of mind for the patient regarding their future care.


Not applicable, as this is a documentation process rather than a medical procedure.


  • Informal verbal communication of wishes, though less legally binding.
  • POLST (Physician Orders for Life-Sustaining Treatment), which is more specific for current medical treatment decisions.

Patient Experience

The patient may experience relief and a sense of empowerment knowing their healthcare preferences are documented. It may also evoke emotional discussions with loved ones but ultimately aims to provide clarity and peace of mind.

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