• David B Simmons, Benjamin H Levi, Michael J Green, In Seo La, Daniella Lipnick, Theresa J Smith, Elizabeth R Thiede, Debra L Wiegand, and Lauren Van Scoy.
• Department of Pastoral Care, Penn State Milton S. Hershey Medical Center, Hershey, PA.
• Am J Hosp Palliat Care. 2021 Jun 24: 10499091211026674.

BackgroundThe goal of advance care planning (ACP) is to improve end-of-life decision-making for patients and their spokespersons, but multiple studies have failed to show substantial or consistent benefit from ACP. Understanding how and why ACP under-performs in the setting of complex medical decision-making is key to optimizing current, or designing new, ACP interventions.AimTo explore how ACP did or did not contribute to a spokespersons' understanding of patient wishes after engaging in ACP.DesignThematic analysis of 200 purposively sampled interviews from a randomized control trial of an ACP decision aid.Setting/Participants200 dyads consisting of patients 18 years or older with advanced serious illness and their spokesperson at 2 tertiary care centers in Hershey, PA and Boston, MA. Participants were interviewed 1 month after completing ACP.ResultsACP helped participants: 1) express clear end-of-life wishes, 2) clarify values, and 3) recognize challenges associated with applying those wishes in complex situations. Shortcomings of ACP included 1) unknown prognostic information or quality-of-life outcomes to inform decision-making, 2) skepticism about patients' wishes, and 3) complicated emotions impacting end-of-life discussions.ConclusionsHelping patients and their spokespersons better anticipate decision-making in the face of prognostic and informational uncertainty as well as the emotional complexities of making medical decisions may improve the efficacy of ACP interventions.

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