Nurse-led Patient-centered Advance Care Planning: A Pilot Study (ACP)
Advance Care Planning, Nurse Care Coordination, Multiple Chronic Health Conditions
About this trial
This is an interventional health services research trial for Advance Care Planning focused on measuring Advance Care Planning, Nurse Care Coordination, Comparative Effectiveness, Advance Directive, Decision Aides
Eligibility Criteria
Patients on the list of each NCC who do not have an Advance Directive on file in the Mayo electronic health record will be invited to participate.
Inclusion Criteria: This study will include community-dwelling adult patients with multiple chronic health conditions who do not have an Advance Directive document on file and their SDM/HCA if identified during the course of the intervention. We will accrue 40 patients and up to 40 SDM/HCAs to participate in this pilot study as subjects (80 total participants).
Exclusion Criteria: Because the ACP process, as part of self-management, is a deliberative process, patients with dementia or a serious, persisting psychiatric diagnosis identified in the medical record will be excluded. Patients whose cannot speak or read English will be excluded since it is beyond the scope of this pilot study to employ interpreters.
No vulnerable populations will be included in this study.
Sites / Locations
- Mayo Clinic in Rochester
Arms of the Study
Arm 1
Arm 2
Arm 3
Arm 4
Active Comparator
Active Comparator
Active Comparator
Active Comparator
Make Your Wishes Known
Mayo Clinic-Advance Health Care Planning
Mydirectives.com
Prepare
A Decision Aid that uses interactions, videos, vignettes. A formatted Advance Directive; saved data that may be revisited to produce a revised Advance Directive
Not an online decision aid Written instructions, worksheets, and Advance Directive to complete
Online decision aid that uses interactions, videos, and vignettes. An electronically stored Advance Directive that may be printed.
An online decision aid that uses interactions, videos and vignettes. A printed summary useful for transposing values and treatment wishes into an Advance Directive; a list of action steps.