Massachusetts Medical Society: Advance Care Planning in Your Office

Advance Care Planning in Your Office

By Ryan Marling
PPRC Specialist

As of January 1, the Centers for Medicare and Medicaid Services (CMS) began reimbursing physicians for consulting with patients and their families about advance care planning (ACP). An ACP visit is a face-to-face conversation between a physician and patient about future care treatment if a health event compromises the patient’s decision-making capabilities. The conversation may include discussion of advance directives.

These appointments can help enhance patient-centered care — care that is respectful of and responsive to individual patient preferences, needs, and values. ACP appointments are intended to ensure that patient values guide all clinical decisions when patients’ conditions prevent them from participating in decision making.

Keep in mind that Massachusetts law allows people 18 years of age or older to name health care proxies, but does not officially recognize living wills. During an ACP visit, encourage patients to discuss their end-of-life wishes with whomever they appoint as agents in their health care proxy document.

Other steps physicians can take include the following:

  • Encourage patients to make at least four copies of the completed and signed health care proxy form and send one copy to you.
  • Urge patients to notify you in writing of any changes they make to their health care proxy form or if the form is revoked.
  • Have Medical Orders for Life- Sustaining Treatment (MOLST) — intended for patients who are clinically viewed as being in their last year of life — and health care proxy forms available. Proxy forms can be found at and MOLST forms at

A brochure to share with patients and further information on advanced care planning is available at

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