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White paper on advance care planning


A lack of consensus regarding the definition of advance care planning (ACP), and a lack of practice recommendations that are applicable to a variety of cultural settings and personal values, have hindered the development of ACP programmes and the evaluation of ACP’s effectiveness.

Objectives of the white paper

We aimed to develop a consensus definition of ACP and present recommendations for ACP that can be used by health-care providers, policy makers, and researchers across a broad spectrum of patient populations, disease categories, and cultures.


Healthcare workers, researchers, policy makers, patients, relatives


Five round Delphi study including literature reviews.


Advance care planning (ACP) is increasingly implemented in oncology and beyond, but a definition of ACP and recommendations concerning its use are lacking. We used a formal Delphi consensus process to help develop a definition of ACP and provide recommendations for its application. Of the 109 experts (82 from Europe, 16 from North America, and 11 from Australia) who rated the ACP definitions and its 41 recommendations, agreement for each definition or recommendation was between 68–100%. ACP was defined as the ability to enable individuals to define goals and preferences for future medical treatment and care, to discuss these goals and preferences with family and health-care providers, and to record and review these preferences if appropriate.

Recommendations included the adaptation of ACP based on the readiness of the individual; targeting ACP content as the individual's health condition worsens; and, using trained non-physician facilitators to support the ACP process. We present a list of outcome measures to enable the pooling and comparison of results of ACP studies. We believe that our recommendations can provide guidance for clinical practice, ACP policy, and research.

Links and Resources


Bud Hammes, Luciano Orsi, Judith Rietjens, Ralf Jox, Margaret Drickamer, Daisy Janssen, Rebecca Sudore, Dirk Houttekier, Agnes van der Heide, Ida Korfage



Judith Rietjens
Department of Public Health
to contact by email please click here

Ida Korfage
to contact by email please click here


Jane Seymour (UK)
Sheila Payne (UK)
Luciano Orsi (IT)
Ralf Jox (DE)
Rebecca Sudore (USA)
Daisy Janssens (NL)
Michael Connolly (IR)
Agnes van der Heide (NL)
Dirk Houttekier (BE)
Hans van Delden (NL)
Margaret Drickamer (USA)
Daren Heyland (CA)
Mirjam Droger (NL)

Expert panel

The panel exists of a little over 100 international experts in several domains (palliative care, elderly care, oncology), from 14 countries, representing different relevant disciplines (physicians, nurses, psychologists, researchers). 



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