1284 The advance care planning conversation – where are we heading? Possible directions from ethical analysis

<h3>Aim</h3> To answer the conference-theme question ‘Are we there yet?’, it is worth contemplating where ‘there’ is, i.e. what we want to achieve with advance care planning (ACP) and what follows to be done. Essentially, ACP shall contribute to realizing the ethical obligation of respecting autonomy when patients have lost decision-making capacity. The task, then, is to elaborate what ACP conversations should comprise and achieve to effectively approach this fundamental ethical goal of ACP. <h3>Methods</h3> Ethically founded analysis of what ACP conversations require to contribute effectively to respecting patients’ autonomy if they have lost decision-making capacity. <h3>Results</h3> Effective ACP conversations should contain at least the following elements: The planning person should first be able to develop her fundamental perspectives on living, severe illness and death, from which the person’s individual goal of care can be inferred. This is a necessary precondition for the subsequent planning of concrete medical treatments. The planning process should then cover typical medical scenarios with decisional incapacity and elicit individual preferences for life-sustaining treatments. We suggest structuring the planning process into three distinct scenarios depending on the available prognostic information:i. Acute emergency situations in any setting, in which prognostic information is limited (e.g. acute cardio-respiratory arrest);ii. continued acute (hospital) care with unclear duration of decisional incapacity, when prognostic information resulting in probabilities for different possible outcomes is available (e.g. acute severe stroke); andiii. chronic care with permanent decisional incapacity (e.g. progressive dementia). For each scenario, the planning person is encouraged to define the respective goal of care and the corresponding limits for medical interventions. The planning process should be conducted according to a shared decision-making (SDM) standard to elicit informed and well-considered treatment preferences. We elaborate how the different steps of the SDM process can be applied to the facilitated ACP process. The person should be encouraged and supported to designate a proxy who can later make substitute medical decisions according to the patient’s preferences. We provide concrete examples from the ACP model of the German ACP society for each element. <h3>Unique Contribution</h3> This presentation provides an ethically justified normative standard for the content of effective ACP conversations. <h3>Implications</h3> The resulting normative guidance can be used to design effective ACP conversations that can achieve the fundamental ethical goal of ACP. Furthermore, it can be used as a standard to evaluate planning conversations in existing ACP programs.