Advance Care Planning Is Evolving — But Our Commitment Remains the Same

Advance Care Planning (ACP) has long been central to who we are as a healthcare community. Its purpose is simple and profound: to ensure the voices of our patients guide their care, that their wishes are honored and that dignity remains at the heart of every decision. That commitment has not changed.

In recent years, PeaceHealth supported ACP through a non-clinical coordinator who provided one-to-one assistance, offered community classes such as Your Voice, Your Choice and served as a resource for patients and caregivers. Yet the numbers told an important story: overall participation in advance care planning was low. In 2025, of more than 56,000 ambulatory patients served, only 682 were referred for ACP in Whatcom and Skagit counties, and just 342 visits were completed — about 0.5% of the total patient population. Class attendance, while meaningful, remained modest.

As we considered sustainability and long-term impact, it became clear that embedding ACP into everyday clinical workflows would better meet the needs of our patients and communities. Non-clinical coordinators played a valued role, but because they could not answer medical questions related to illness progression, many patients still required follow-up with their care team. This created complexity in the process and placed added responsibility on our patients.

Today, ACP is no longer the responsibility of a single individual — it is integrated into routine care across our ambulatory settings. This approach ensures more people receive information and have the opportunity to participate in ACP planning. Clinicians receive ACP training, annual wellness visits include these discussions and check-in workflows now identify patients who haven’t had ACP conversations within a year. Since Feb. 12, more than 100 patients have had ACP discussions documented under this new approach, a significant increase over the prior year.

Updated electronic health record tools, patient-facing reminders and our patient portal (called MyPeaceHealth) allow people to upload their advance directive documents right into their medical record, further supporting this work.

The model has evolved, but the mission remains unchanged: every patient’s values deserve to be heard, respected and integrated into their care.