Initiating advance care planning and DNACPR conversations in the emergency department: A narrative review and reflective case analysis to inform nursing practice

AIM: To explore considerations for initiating advance care planning (ACP), particularly regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders in the Emergency Department (ED). This article integrates evidence from the literature with reflective analysis of real-world cases to inform clinical education and training for healthcare professionals. BACKGROUND: ACP enables individuals to express their values and preferences for future care, especially when decision-making capacity may be lost. Despite its significance, initiating ACP in the ED remains challenging due to clinical urgency, limited patient information, and time pressures. As around half of older adults attend the ED in their last month of life, the setting offers a vital but underused opportunity for timely, patient-centred conversations. METHODS: A narrative review with integrated practice-based reflective pedagogical analysis was conducted. To enhance transparency, a structured search of CINAHL and MEDLINE (2009-2024) was undertaken, supplemented by Google Scholar and reference list screening. Seven anonymised ED clinical scenarios were analysed using a structured reflective framework. FINDINGS: Nurses, through their close patient engagement and communication expertise, are well placed to initiate ACP discussions. However, they require enhanced communication training, legal awareness, and institutional support. Reflective, case-based learning helps translate theoretical knowledge into confident practice within time-critical environments. IMPLICATIONS: Embedding ACP and DNACPR communication training into nursing education and professional development may strengthen confidence, improve patient-centred care, and reduce decisional conflict at the end of life.