Incorporating Life Care Planning into Specialty Care Populations


Matthew Handley, MD; Melissa Stern, MBA

Though most people say they are willing to discuss end of life and agree that documenting their wishes is important, only a very small number actually do. When the process is done well, it has the power to produce a written plan that accurately represents the individual’s preferences and thoroughly prepares others to make health care decisions consistent with these preferences. Life Care Planning is a National Quality Initiative driven by the six aims to deliver care that is patient-centered, effective, efficient, equitable, timely, and safe. It is currently being implemented in five Regions with a sixth to begin before year-end. This presentation describes an evidenced-based approach for ensuring that patients facing a life-threatening illness align the care given to their personal values and wishes and demonstrates how to integrate the methodology into “normal routine” care within the Nephrology and Cardiology specialties, which serve as examples of how it may be applied to any specialty. Making these decisions is difficult and the implications for not making them can have significant impact on patients, their families, and practitioners. This evidenced-based approach ensures patients are supported and guided in an unbiased and nonjudgmental way.

Reprint Permissions

The Permanente Journal welcomes requests for reprints and reproduction. Use of any and all published materials is copyrighted and protected.


Journal subscriptions for The Permanente Journal are entered for the calendar year. Advance payment in US dollars is required.


27,000 print readers per quarter, 15,350 eTOC readers, and in 2018, 2 million page views of TPJ articles in PubMed from a broad international readership.


Indexed in MEDLINE, PubMed Central, HINARI, EMBASE, EBSCO Academic Search Complete, rdrb, CrossRef, and SciVerse/Scopus.




ISSN 1552-5767 Copyright © 2019

All Rights Reserved.