Question 1

When is the right time to start ACP?

Accepted Answer

ACP should be initiated early in the trajectory of a life-limiting illness, not deferred until a crisis. The surprise question ('Would I be surprised if this patient died in the next 12 months?') is a practical trigger. Earlier ACP is associated with better goal-concordant care and less aggressive end-of-life interventions.

Question 2

Can ACP be done with patients who lack decision-making capacity?

Accepted Answer

ACP ideally occurs while the patient still has capacity. For patients who lack capacity, the conversation shifts to the surrogate decision-maker, guided by any previously expressed wishes or the patient's known values (substituted judgement). Some jurisdictions allow advance directives to be completed by a surrogate.

Question 3

Do advance directives reduce life-sustaining treatment in hospital?

Accepted Answer

Yes — multiple systematic reviews show that patients with advance directives are significantly less likely to receive unwanted CPR, mechanical ventilation, or ICU admission at the end of life, without evidence of increased mortality. ACP also improves family satisfaction and reduces bereavement anxiety.

Question 4

How often should ACP documentation be reviewed?

Accepted Answer

ACP should be reviewed at significant health milestones (new diagnosis, decline in functional status, hospitalisation, care transition) and at least annually. Preferences can change as the illness evolves or as the patient adapts to their condition.