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Date of Award


Document Type


Degree Name

Master of Science in Nursing (MSN)



Thesis Committee Chairperson

Wencan Lu, DNP, FNP, RN

Additional Advisor

Jennifer Huber, AGNP, RN, MSN


advance care planning, advance directive, engagement, primary care, web-based


Clinical Problem: Clinical observation and research revealed that, despite current advance care planning (ACP) methods, the completion of advance directives (ADs) is low. Although webbased strategies to increase older adult engagement in ACP have been studied, they have not been applied in current practices. Web-based ACP tools have been found to be feasible, easily accessible, and effective for improving ACP knowledge, communication, and documentation (van der Smissen et al., 2020). However, they are not yet standardized in the primary care setting.

Significance: The burden created by a lack of engagement in ACP is vast. The wishes of those at the end of life may be unknown, which can result in the delivery of unwanted treatment. An emotional burden on patients and their loved ones can also result from a lack of end-of-life preparation (Meghani & Hinds, 2015). There is a significant impact on healthcare costs in relation to unwanted treatment at the end of life (Howard, Bernard, Klein, Elston et al., 2018). Increasing older adult engagement in ACP has the potential to reduce these burdens and improve the quality and consistency of their received patient care.

PICOT Question: This evidence-based practice proposal aims to answer the question, “Among older adult patients in the primary care setting, would a web-based tool increase engagement in advance care planning?”

Clinical Change: The proposed clinical change is the promotion of the PREPARE website ( by primary care providers to increase ACP engagement among adult patients, aged 55 or older.

Desired Outcome: The desired outcome of implementing the proposed clinical change is an increase in the overall engagement of older adults in ACP in primary care. This includes documentation of completed ADs and patient-reported engagement in contemplation about their wishes and ACP discussions.

Summary: Through a review and synthesis of the literature, it was determined that web-based interventions are effective for promoting older adult engagement in ACP. This evidence-based proposal delineates an implementation plan for an ACP website called “PREPARE” to be adapted for the primary care setting. The objectives are reducing the burden that comes with a lack of ACP engagement and achieving patient-centered outcomes.