{"doi":"10.1111/jgs.18287","title":"The care planning umbrella: The evolution of advance care planning","abstract":"Advance care planning (ACP) was initially narrowly defined as documentation of life-sustaining treatment (LST). One initial goal was to curb unwanted LSTs and costs.1 Yet, a focus solely on legal documentation of LST preferences has resulted in mixed data on goal-concordant care and healthcare utilization.2-4 Fortunately, the conceptualization of ACP continues to evolve, and is now widely recognized as a process of preparing patients (people) and surrogate decision-makers for communication and medical decision-making.5, 6 This process involves a complex array of patient, surrogate, and clinician behaviors, health systems workflows, interventions, communities, and policy. ACP is rooted in what quality of life means to people.4, 5, 7 However, antiquated narrow definitions of ACP as a one-time checkbox or code status persist, resulting in heterogeneous research, clinical, and policy initiatives.2, 4 To address this heterogeneity, a modified Delphi panel defined ACP in 2017 as “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.”7 As the field has evolved, this definition focused on “future decisions” has proven to be too narrow as it does not include the preparation of patients and surrogates for decision-making over the life course or address public perceptions of ACP.8-10 The use of non-standardized and potentially inappropriate ACP outcomes in research also makes it difficult to evaluate ACP's effectiveness.4, 11 Goal-concordant care has been considered the “gold standard,” but there is a lack of validated or standardized measures.12-15 Because patient preferences may change, reliance on retrospective chart review to assess goal concordance may be inaccurate,13, 14 and there is a growing consensus that surrogate outcomes should be one key focus of ACP research.6 Additionally, ACP is unlikely to affect some outcomes such as quality of life, which may be impacted by other factors such as symptom burden, available support, and so forth, or healthcare utilization, which is not patient-centered and affected by lack of healthcare access, systemic injustice, and other issues.12, 16 Furthermore, the unique needs of historically marginalized populations are not well represented in prior definitions and outcomes identification. Rates of ACP are much lower (<20%) among racially or ethnically minoritized populations and those with limited health literacy.17-19 Disparities in ACP also persist for lesbian, gay, bisexual, transgender, queer, intersexual, asexual, homeless, and incarcerated populations.20, 21 Reasons may include lack of access to healthcare, experiential discrimination, well-founded mistrust,22, 23 and culturally diverse views on autonomy and decision-making,24, 25 making it preferable for many to begin care planning discussions in their communities. Diverse communities, as well as interdisciplinary clinicians and community-based experts, have not been included in prior efforts to define ACP and ACP outcomes. We propose a new framework that reflects the updated focus on preparation for communication and medical decision-making and conceptualizes ACP as part of the continuum of care planning. The overarching construct under the “Care Planning Umbrella” focuses on preparation for communication and medical decision-making,5 with quality of life and what brings meaning and purpose as the fundamental cornerstone. Underneath this broader umbrella are multiple steps, behaviors, people, clinical and community workflows, and decisions—some of which are in-the-moment and some in advance. Care planning is shaped by the person's (or surrogate's) perceptions of quality of life; understanding that these constructs are dynamic and evolve over time.28 It is also shaped by an individual's readiness, preferences for control over decision-making, illness understanding, prognostic awareness, and views of acceptable/unacceptable","journal":"Journal of the American Geriatrics Society","year":2023,"id":315875,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":129,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9564,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2023-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":260420,"name":"Hillary D. Lum","orcid":"0000-0001-5637-3912","position":1,"is_corresponding":false},{"id":505334,"name":"Anne M. Walling","orcid":"0000-0001-6026-3249","position":2,"is_corresponding":false},{"id":513748,"name":"April Savoy","orcid":"0000-0001-9002-9234","position":3,"is_corresponding":false},{"id":237755,"name":"Rebecca L. Sudore","orcid":"0000-0003-4436-2209","position":4,"is_corresponding":false},{"id":401720,"name":"Susan E. Hickman","orcid":"0000-0003-1514-8430","position":0,"is_corresponding":true}],"reference_count":43,"raw_metadata":null,"created_at":"2026-07-19T01:06:32.274501Z","pmid":"36840690","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}