Date of Award

Summer 8-9-2022

Document Type

Scholarly Project

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

David Liguori, DNP, NP-C, ACHPN

Second Advisor

Robert W. Kentner, DNP, RN, CPHQ, CEN, TCRN


Practice Problem: One in three adults aged 55 and older admitted to the hospital lack advance care planning. Patients without advance care planning may not receive treatment that reflects their personal values, wishes, and preferences

PICOT: The PICOT question that guided this project was in adults 65 years or older (P), how does the implementation of a patient-centered web-based advance planning tool kit (I) compared to the usual practice of addressing advance care planning (C), affect the completion rate of advance care planning documentation (O) within 10 weeks (T).

Evidence: The current evidence has demonstrated that advanced care planning promotes patient-centered care by ensuring patients’ personal preferences regarding medical care are understood. Patients that receive care that is consistent with their personal preferences decrease the burden of family members having to make difficult healthcare decisions when patients are unable to make decisions for themselves. The benefits of advance care planning also extended to the healthcare team by reducing the costs associated with expensive treatments and hospitalizations.

Intervention: The intervention utilized the PREPARE Tool to educate participants on advanced care planning. The tool was easily accessible on the internet which provide the steps required for completing an advance directive.

Outcome: The project results demonstrated that the implemented web-based PREPARE tool increased the completion of advance care planning.

Conclusion: The goal of this change project was to increase awareness and the completion of advanced care directives. To ensure patients remained at the center of care, the PREPARE too was utilized to provide education on advance care planning to participants in the community resulting in a significant increase in completed advanced directives.


Scholarly project submitted to the University of St. Augustine for Health Sciences in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice.

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This work is licensed under a Creative Commons Attribution 4.0 License.