Date of Graduation

Summer 8-11-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Francine Serafin-Dickson


Problem: Transition patients at the end-of-life are those patients who are not mentally ready or physically eligible for hospice thus not enrolled in a Palliative or Hospice Program. Only one-third of the Transition patient census had completed and filed advance care plans. Healthcare providers are obligated to perform life-saving measures unless documented otherwise. A lack of advance care planning can create complicated scenarios and cause discordant care incidents.

Context: End-of-life care is a delicate subject to navigate conversations with patients. With holistic care being a large component of hospice and palliative care, it is important to have updated and accurate advance care plans for all patients, including Transition patients.

Intervention: A training program was developed and conducted with volunteers to assist patients to better identify and document their end-of-life wishes, care goals, and values.

Measures: Competency quizzes conducted online before and after training were collected to determine the program’s efficacy and retainment of knowledge. A score of 80 percent was considered a passing rate, and the aim was an overall average increase of knowledge by 15 percent across all the volunteers. Long-term measures include 100 percent of patients having received a follow-up and having completed and electronically filed advance care plans.

Result: No volunteer reached the 80 percent competency rate with the pre-test. However, all volunteers increased their knowledge as indicated with a better score greater than or equal to 15 percent than the pre-test. The average post-training score was 93 percent.

Conclusion: Advance care plans support patient autonomy and preserve patients' ability to be informed and involved in their care. Training volunteers to follow-up and educate Transition-enrolled clients about advance care planning will benefit the patient, the patient’s family, and the healthcare system.