Date of Submission

Fall 12-11-2019

Document Type


Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Karen Van Leuven

Second Advisor

Wanda Borges


It has been well documented that the majority of people want to spend their last days in the comfort of their own homes, free of pain, and off any dependent machine. , However, the majority of people have not documented these wishes or talked with their family or provider about end of life care (Hamel, Wu, & Brodie, 2017). The Patient Self Determination Act (PSDA), which took effect on December 1, 1991, was enacted to raise awareness and promote discussions between patients and providers about end of life (EOL) healthcare decisions. The primary care nurse practitioner is in a prime position to initiate advance care planning (ACP) interventions with patients and their loved ones to help ensure they receive the care that is most consistent with their goals, preferences, and values. As our aging population continues to grow, so will the demand for healthcare services; therein making the case to develop innovative and efficient initiatives to increase public awareness, empower community members, and advocate for patient’s rights to take control of their health care wishes.

A Community-Based Advanced Care Planning Program was developed in collaboration with facility staff, a partnering provider group, and University of San Francisco faculty and integrated into a retirement community . A pre-/post-survey design was used to evaluate this intervention. Survey data were analyzed by way of comparative means and tested for level of significance using a paired t-test. Results of this intervention indicate that participants had significantly increased in all outcome measures including knowledge of ACP processes and documents. Participants also demonstrated a significant increased level of confidence and expressed that on average, they were more likely to designate a durable power of attorney for health care and discuss their goals of care with their family and provider after the intervention.