What Matters Most: Leadership’s Role in Meaningful Advance Care Planning
By Lisa Thomson, BA, LNHA, HSE, CIMT, Chief Operating Officer, Pathway Health
In today’s post-acute and long-term care settings, few conversations carry as much importance—or as much heart—as those about a resident’s wishes for their care.
Advance Care Planning (ACP) is more than a form or a regulation—it’s an opportunity to listen, understand, and ensure that each person’s values and goals guide the care they receive.
For leaders such as Nursing Home Administrators (NHAs), Directors of Nursing (DONs), and Directors of Social Services (DSS), how we approach and support these conversations reflects our organization’s culture and commitment to person-centered care. Leadership has a powerful influence. When ACP is encouraged, modeled, and integrated into daily practice, it helps ensure that every decision begins with compassion and respect.
Why Advance Care Planning Matters
CMS Appendix PP, F578, affirms that every resident has the right to make choices about their care—including the right to accept or refuse treatment. This regulation provides the foundation, but the true impact of ACP reaches far beyond compliance.
When residents and families are invited to discuss their preferences early and revisit them as needs change, the results are deeply meaningful: fewer unwanted interventions, smoother care transitions, and greater peace of mind for all involved. Research consistently shows that when ACP is done well, residents experience care that better reflects their wishes, families feel supported, and staff feel more confident in their roles.
As our population ages and health needs grow more complex, thoughtful and ongoing conversations about what matters most are becoming an essential part of quality care.
Guiding Conversations that Matter – Leadership’s Role
1. Culture Begins with Leadership: When leaders openly support and normalize ACP discussions, staff are encouraged to view them as a natural and valued part of care—not an uncomfortable topic. Recognizing and reinforcing these efforts helps build a culture rooted in empathy and respect.
2. Compliance is the Starting Point, Not the Goal: Appendix PP provides the framework, but ACP comes to life through understanding and connection. Leaders can help ensure that staff are not only aware of the requirements but also comfortable and confident in having meaningful conversations with residents and their families.
3. Equip and Support Your Team: ACP conversations can feel challenging, especially for newer staff. Providing education, mentorship, and practical tools—like conversation guides or real-life scenarios—helps staff approach discussions with sensitivity and confidence.
4. Make ACP a Routine Part of Care: From admission through care plan meetings and change-of-condition reviews, ACP should fit naturally into the care process. Ensuring clear documentation and communication between shifts and settings helps keep everyone aligned with the resident’s preferences.
5. Engage Families with Compassion: Families often bring emotion, uncertainty, and love to these conversations. Leaders can help staff approach families with patience, cultural awareness, and an emphasis on listening first—ensuring everyone feels heard and supported.
Four Ways Leaders Can Strengthen ACP in Their Organization
1. Make ACP Part of Your Quality Strategy: Include ACP in your QAPI goals. Track progress and celebrate improvement—such as when more residents have documented preferences or when successful family discussions occur.
2. Provide Ongoing Education for All Staff: Use your LMS or virtual training tools to deliver approachable, interactive learning on ACP. Reinforce both the practical and emotional skills needed to guide meaningful conversations.
3. Model the Behavior You Want to See: When leaders demonstrate openness and understanding around ACP—sharing their own reflections or encouraging gentle dialogue—it helps create a safe environment for others to do the same.
4. Build a Culture of Reflection and Learning: Take time to acknowledge staff who handle ACP conversations thoughtfully. Use team huddles or debriefs to share lessons learned and celebrate when resident wishes successfully guide care.
The Heart of It All
When Advance Care Planning becomes part of the fabric of care, residents feel valued, families feel reassured, and teams feel confident that their work truly makes a difference. As leaders, we have the privilege and responsibility to make space for these meaningful conversations—to ensure that, even in moments of uncertainty, care reflects what matters most to each person we serve. That is the heart of leadership in post-acute care: honoring every voice, supporting every choice, and guiding care with compassion and clarity.