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Allsun Moran

Date of Award


Document Type


Degree Name

Master of Science in Nursing (MSN)



Thesis Committee Chairperson

Dr. Deborah Merriam, DNS, MS, RN, CNE

Additional Advisor

Shannon O’Brien, ANP-BC, RN, BSN


advanced care planning, advanced directive, end-of-life, goals of care, palliative care


Clinical Problem: Despite the research indicating the positive outcome of advanced care planning (ACP), completion rates of advanced directives remain overall only around 25% (Ma et al., 2020). Outpatient primary care provides an ideal setting for advanced care planning discussions to promote advanced directive completion, yet barriers continue to exist.

Significance: When health-care delivery is in line with the patients’ values and goals of care at the end of life it increases patient and family satisfaction and empowerment, enhances comfort and dignity, prevents unnecessary intervention and suffering, and decreases hospital costs. Delayed discussions with patients and family members lead to increased instances of psychological and emotional distress when faced with the burden of having these conversations in an acute setting with unknown providers (Ma et al., 2020). Advanced care planning and goals of care (GOC) discussions aimed to complete advance directives (ADs) are a way in which the patient and provider can ensure that care delivery at the end of life is in accordance with these values.

PICOT Question: The purpose of this evidence-based proposal will be to examine and explore the implementation of the PREPARE program in the completion of advanced directives. “In patients, greater than 65 years old will the PREPARE program increase the likelihood of advanced directive completion?”

Clinical Change: The proposed clinical change is to implement the PREPARE program in an outpatient primary office to increase advanced care planning discussions and the completion of advanced directives.

Desired Outcome: The desired outcome for the implementation of the proposed clinical change is an increase in advanced care planning and the completion of advanced directives in the outpatient setting in patients 65 years and older.

Summary: An outline for implementation of the PREPARE program in an outpatient primary care office was described, and contextual factors, systems focus, budgets, and return on investments were evaluated to promote the feasibility of the project. The given proposal has provided a detailed plan and highlighted the benefit of the implementation of the PREPARE program in the outpatient primary care office, to improve patient-centered outcomes in advanced care planning.