Date of Award


Document Type


Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Amy Lask


Background: The adult population 65 years of age and older is increasing, but a lack of advance care planning discussions has led to poor completion of advance directives. Advance directives express one’s medical wishes once they are not able to make their own decisions and are approaching the end of their life. Advance directives prevent futile care that patients do not want.

Problem: Lack of knowledge, lack of time, and unwillingness to discuss advance directives prevent providers from including advance care planning in their current workflow. Advance directives are important to provide in the long-term care setting, as these patients often have multiple comorbidities and are at higher risk for hospital readmission.

Methods: Participants included patients aged 65 and older who are residents of a skilled nursing and rehab facility. They must be admitted for at least one week and be able to make their own medical decisions.

Intervention: The DNP project leader initiated advance care discussions using the PREPARE conversation guide. Patients received an advance care discussion guide published by PREPARE and reviewed it with the DNP project leader and family members. Completion of the advance directive was measured at the time of and one week after the intervention.

Results: There was a statistically significant increase in post-implementation advanced directive completion scores compared to baseline completion scores (p = .006)

Conclusion: The PREPARE point-of-care tools improved completion of advance directives and aided in advance care planning discussions in older adults.