1. Identification of High-Priority Clinical Scenarios

Summary: Early recognition of patients with critical trajectories is essential to align treatment with patient values and avoid unwanted interventions. Identifying these scenarios promptly allows for timely goals-of-care discussions.

Tier 1 Triggers for Urgent ACP

• Multi–organ failure: Dysfunction of two or more organ systems is a hallmark of critical illness, carrying an ICU mortality of 40–50% or higher.
• Refractory shock: Defined as persistent hypotension requiring a norepinephrine equivalent dose >0.1 µg/kg/min for at least 6 hours. This state is associated with a 28-day mortality exceeding 60%.
• High expected mortality: An estimated mortality risk >50% based on clinical gestalt or validated disease-specific calculators (e.g., MELD score >25 for liver failure, INTERMACS profile 1 for cardiogenic shock).

Urgency: For any of these Tier 1 scenarios, the goal is to initiate a goals-of-care discussion within 24–48 hours of ICU admission.

2. Prognostic Scoring Systems

Summary: Standardized scoring systems like APACHE II and SOFA provide objective mortality risk stratification. They are valuable tools to guide the timing and intensity of ACP, complementing clinical judgment.

Integration into Workflow

• Define automated triggers: An APACHE II score ≥25 or a SOFA score ≥8 can generate an automated EHR alert for the clinical team.
• Promote interdisciplinary review: These alerts should prompt an interdisciplinary case conference involving palliative care, social work, and nursing within 72 hours to formulate an ACP strategy.

3. Social Determinants of Health (SDOH) Influencing ACP

Summary: Health literacy, cultural beliefs, and socioeconomic barriers profoundly impact a patient’s ability and willingness to engage in ACP. Systematic screening and tailored strategies are required to ensure equitable access to these crucial conversations.

• Health Literacy: Utilize validated tools like the Brief Health Literacy Screen. For patients with identified needs, provide low-literacy decision aids, such as the PREPARE website, which uses simple language and videos.
• Cultural Beliefs: Recognize that decision-making norms vary. Some cultures prioritize family-centered decisions over individual autonomy. Engage cultural mediators or faith leaders and provide materials in the patient’s primary language.
• Socioeconomic & Access Barriers: Screen for social needs like transportation, housing, and food insecurity. Leverage patient navigators, who have been shown to double ACP documentation rates in some populations.

Workflow Strategies for Equity

Delegate specific ACP tasks, such as introducing concepts or providing educational materials, to trained nurses or social workers. This team-based approach is reimbursable under CMS guidelines (requiring ≥16 minutes of conversation). Furthermore, linking SDOH screening results directly to ACP order sets and prompts within the EHR can hardwire equity into the clinical workflow.

4. Chronic Disease Considerations in ACP

Summary: The content and timing of ACP should be tailored to specific chronic disease trajectories. Discussions should be anchored to key clinical milestones rather than being reserved for end-of-life crises.

• Dementia: Initiate ACP at the time of diagnosis or when mild cognitive impairment is first noted. It is vital to engage surrogates early and use structured decision aids (e.g., ACT-Plan) to boost their confidence and self-efficacy.
• COPD: Revisit ACP iteratively, especially at the first hospitalization for an exacerbation, initiation of home oxygen, or with increasing frequency of exacerbations. Key topics include preferences for noninvasive ventilation and goals for dyspnea management.
• Heart Failure: Plan for future decisions regarding device management, such as ICD deactivation. Tie ACP conversations to transitions to NYHA Class III–IV symptoms, new inotrope dependence, or frequent hospitalizations.

ACP as an Ongoing Process: Consensus guidelines emphasize that ACP is a dynamic, continuous communication process that evolves over a person’s life course, not a one-time event focused on completing a form.

5. Clinical Decision Algorithm for Patient Prioritization

Summary: A structured, stepwise algorithm ensures systematic identification and timely initiation of ACP conversations across care teams, minimizing missed opportunities and standardizing care.