Date of Award

Spring 5-5-2023

Document Type

DNP Project

Project Team Faculty Member

Dr. Danielle Loftus

Project Team Faculty Member

Dr. Greg Jennings


Advanced care planning, POLST form, end-of-life care, do-not-resuscitate (DNR), primary care


In Illinois, the do-not-resuscitate (DNR) form that is legally binding in all healthcare facilities is known as the Practitioner Orders for Life-Sustaining Treatment (POLST) form. The Patient Self-Determination Act (PSDA) of 1991 mandates only certain facilities to discuss advanced care planning (ACP). Primary care offices are not included in this mandate. Therefore, no structured process exists for primary care providers to identify patients who may benefit from ACP discussions. The purpose of this Doctor of Nursing Practice (DNP) project was to initiate conversations about ACP with patients 55 years and older in a primary care office and complete POLST forms when appropriate. A screening form was implemented into the clinic’s electronic medical record (EMR) which would prompt the intake staff to ask any patient 55 years or older if they had any advanced directives. If a patient answered no, the provider was notified by placing ACP forms outside the patient’s room to signal the provider to have a discussion with the patient. This project was implemented over a period of two months and the data gathered was compared with ACP on file before and after implementation. Prior to implementation, 20% of patients had ACP on file, and 19.4% after implementation, which is a decrease of 0.6%. The future recommendation for this project is to implement it in multiple primary care offices over a year to gain a broader, larger, and more diverse population of patients for the purpose of outcome evaluation.

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