Advance care planning (ACP) is a critical way to align patients’ goals and values with their medical care. These conversations can feel difficult for individuals and families — for example, when weighing whether to pursue life‑prolonging treatment that may extend time but limit comfort or independence — as they consider future health care decisions. 

Yet when these conversations do take place, they often become a meaningful gift — providing clarity, easing the burden of decision‑making and ensuring that care aligns with what matters most to the patient.

Despite its importance, studies consistently show that the number of people who complete ACP documentation remains low. Common barriers include gaps in care between settings, inconsistent documentation, difficulty accessing ACP information in electronic health records (EHRs) and insufficient clinician education.

“For advance care planning to be truly effective, it must be an ongoing, iterative process,” explained Nathan Fairman, a health sciences clinical professor in the Department of Psychiatry and Behavioral Sciences at UC Davis Health. “A system‑wide approach is essential — one that consistently identifies patients who need support with ACP and ensures resources are accessible and available across every care setting where patients are seen.”