Healthcare Professionals

Getting your patients the medical care that is right for them

We invite you to reduce the time and emotional burden of engaging your patients in your advance planning conversations by using our decision aid Guides. Decision support tools like ours have been shown to improve quality of decision-making and numerous patient outcomes, including: 

What is Plan Well?

Plan Well provides patients with Guides so they can optimally plan for future periods of serious illness. The Guides cover various topics from types of medical treatment, to determining authentic values, to how to appoint a representative in case of incapacitation.

Our Guides are different from traditional advance care planning because we encourage patients to identify and communicate their values in preparation for future decision making, rather than making uninformed decisions in advance.

Advance Serious Illness Planning:

Traditional Advance Care Planning:

Dr. Daren Heyland

Plan Well Guide was created by critical care physician and researcher Dr. Daren Heyland, who has been studying communication and decision-making for seriously ill patients for more than 20 years.

He and his colleagues have conducted many research projects through the Canadian Researchers at the End of Life Network (CARENET), the results of which have been used to inform the development of this planning tool.

How to use Plan Well Guides in your practice setting:

You can use this serious illness planning tool to help your patients better understand the different types of medical care and what would be important to them during serious illness.

The website will generate a free Dear Doctor Letter after the patient completes their plan. They will be able to share this letter with you which will help them communicate their values and preferences for medical care.

In general, we recommend that the attending or primary care physician or nurse practitioner directs the patient to go to to complete the planning process on their own. Download our toolkit for helpful materials to give to patients to encourage them to do this process.

We encourage patients to visit with their doctor upon completion of their Plan to resolve their outstanding questions and have you translate their values and preferences into a medical order for the use of life-sustaining treatments.

Direct your patients to to complete their Advance Serious Illness Plan

Upon completion, discuss the contents of their Dear Doctor Letter and answer their questions

Encourage your patients to share their plan with their family and appoint someone to represent them when they are seriously ill

The Plan Well Dear Doctor Letter

The completed Dear Doctor Letter translates well into medical order forms. For an example of a health care system that works well with Plan Well Guide, click below:

If you do not work in a health care system that has a medical order for the use of life-sustaining treatments (e.g. “Goals of Care Designation Form”, “Medical Order for Life-Sustaining Treatments”, “POLST”, etc.), the finalized Dear Doctor Letter serves as the communication script with future ICU, ER or other doctors making serious illness treatment decisions with your patient or their appointed representative.

Adapt to your Setting

Depending on your setting, this approach may require some adaptation. For example, if you have access to allied health care professionals or volunteers who can engage the patient and review the website with the patient and/or family, that may work better.

Alternatively, if the doctor sends the patient home to review the website independently, an allied health professional or volunteer may meet with the patient before they meet with the doctor again to ensure they have gone through the website and understood the information presented.

Some patients may prefer to work on paper, not online. To accommodate this preference, we have a downloadable paper version (see below) of this website where the last 4 pages serve as the equivalent of the Dear Doctor Letter.

Creating a Culture of Advance Serious Illness Planning in your Practice Setting

Research has shown that patients expect their doctors to bring up the discussion of planning for serious illness, but most doctors do not because they feel the patient will not be ready, the conversation will be difficult, and/or it will take too much time. Plan Well Guide can help both doctors and patients.

For patients, we provide tools to help them to communicate their values, medical preferences and outstanding questions as it relates to serious illness. We help them become decisionally ready so it will require less of your time and energy.

For doctors, we provide resources to create an environment in which thinking and planning ahead is normalized. Creating a culture of planning ahead for future serious illness in your practice setting will condition your patients to expect that you will discuss it with them, and motivate them to prepare in advance for those discussions.

We have resources and posters available for clinic use, which you can download below.

Healthcare Resources

Waiting Room Videos

If you wish to play any of our videos on a TV/ computer in your waiting or exam room, please contact us.

Available videos:

  • CPR Decision Aid
  • ACP Conversations
  • Deciding on an Representative (substitute decision maker) 
  • Being an Representative (substitute decision maker) 
  • What if you were hit by a bus?
Advance Serious Illness Planning on Paper

Available in French and English, for individual use and for ordering in bulk from print shops. 

Printable Promotional Materials

In one click, download a zip file containing all of our complimentary promotional materials needed for your practice setting.

Includes: all 6 posters, our informational postcard, and one-pager information sheet

Conversation Guide

This Guide provides a framework including scripts to assist you with engaging patients and/or their Representatives in goals of care (GOC) conversations

Goals of Care Worksheet
  • designed for those who haven’t been through the website or the pamphlet but who you want to use the constraining values scales and the grid to guide your conversation in the moment.
  • can be used when you are seeing the patient in the clinic, the ER, or on the wards
Prescription Pad

A downloadable prescription pad gives you a convenient way to encourage your patients to visit the Plan Well website

Advance Serious Illness Planning Walkthrough Videos with Dr. Daren Heyland
  • How to optimally elicit patients’ values to inform decision-making​
  • How to optimally elicit patients’ values to inform decision-making​
  • Planning for Serious Illness vs. Planning for Death​
  • Advance Instruction Directives: How useful are they?

Plan Well Publications

Dr. Daren Heyland and colleagues have been scientifically validating the Plan Well system in clinical settings for over 20 years. The Guides you see today are the culmination of those years of research. To read more about how we got here and how our Guide was developed, feel free to browse through our publications:

We published an article in the journal Health Expectations detailing the process of English to French translation and cultural adaptation of the Plan Well Guide.

Randomised trial of a serious illness decision aid (Plan Well Guide) for patients and their Representatives to improve engagement in advance care planning.

In a post-hoc subgroup analysis, there was a significant difference in favour of the Plan Well Guide group in participants with a lower-than-median baseline score compared with those at or above the median. The use of Plan Well Guide led to a significant improvement among Representatives (formerly called Substitute Decision Makers) who were the least prepared at the start.

A randomized trial of Plan Well Guide was recently published in CMAJ Open. The results showed that Plan Well Guide improves decision quality, patient and physician satisfaction, and reduces time physicians spend on their interactions with patients.

Articles by Year

November 25

Patient Education and Counseling, Volume 104 – Issue 4: Effect of “Speak Up” educational tools to engage patients in advance care planning in outpatient healthcare settings: A prospective before-after study

September 23

MedRxiv Preprint: Supporting decision-making on allocation of ICU beds and ventilators in pandemics

September 17

ICU Management & Practice, Volume 20 – Issue 3: Unmasking the Triumphs, Tragedies, and Opportunities of the COVID-19 Pandemic

September 1

Australian Critical Care, Volume 33 – Issue 5: Shared decision-making in the intensive care unit requires more frequent and high-quality communication: A research critique

August 11

The Royal College of Physicians and Surgeons of Canada: New tool helps patients plan for serious illness care

July 18 

Healthcare, MDPI, Volume 8 – Issue 3: Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)

July 10

Ontario Hospital Association: Supporting Patients in Getting the Medical Care that Is Right for Them

June 3

Canadian Geriatrics Journal, Volume 23 – Number 2: The Impact of Prior Advance Care Planning Documentation on End-of-Life Care Provision in Long-Term Care

June 1

Canadian Medical Protective Association Practically Speaking Podcast: COVID-19: Advance care directives

May 25

BMC Family Practice, Volume 21- Number 94: Exploring patient-reported barriers to advance care planning in family practice

May 21

Canadian Hospice Palliative Care Association: Become a CHPCA Associate or Affiliate / Provincial Member

May 1

Canadian Geriatrics Journal, Volume 23 – Issue 2: The Impact of Prior Advance Care Planning Documentation on End-of-Life Care Provision in Long-Term Care

Journal of Post-Acute and Long-term Care Medicine, Volume 21 – Issue 5: A Multicenter Study to Identify Clinician Barriers to Participating in Goals of Care Discussions in Long-Term Care

April 28

Canadian Medical Association Journal, Volume 8 – Issue 2: A novel decision aid to help plan for serious illness: a multisite randomized trial

March 2020

The Annals of Family Medicine, Volume 18 – Issue 2: Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings

March 25

Family Practice, Volume 37 – Issue 2: Primary care clinicians’ confidence, willingness participation and perceptions of roles in advance care planning discussions with patients: a multi-site survey

January 19

The Lancet: EClinicalMedicine, Volume 19: Advance care planning; we need to do it more, but it needs to be done differently

February 1, 2018

Journal of Pain and Symptom Management, Volume 55 – Issue 2: Outcomes That Define Successful Advance Care Planning: A Delphi Panel Consensus 

January 1, 2018

Journal of Pain and Symptom Management, Volume 55 – Issue 1: Development and Psychometric Properties of a Survey to Assess Barriers to Implementing Advance Care Planning in Primary Care

December 6, 2017 

BMC Medical Informatics and Decision Making, Volume 17 – Number 164: Recognizing difficult trade-offs: values and treatment preferences for end-of-life care in a multi-site survey of adult patients in family practices

November 1, 2017

Journal of Cardiac Failure, Volume 23 – Issue 11: Barriers to Goals of Care Discussions With Patients Who Have Advanced Heart Failure: Results of a Multicenter Survey of Hospital-Based Cardiology Clinicians

September 1, 2017

BMJ Supportive & Palliative Care: Discordance between patients’ stated values and treatment preferences for end-of-life care: results of a multicentre survey

The Lancet: Oncology, Volume 18 – Issue 9: Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care

July 31, 2017

Canadian Medical Association Journal, Volume 189 – Issue 30: Validation of quality indicators for end-of-life communication: results of a multicentre survey

June, 2017 

Journal of Critical Care, Volume 39: Development and initial evaluation of an online decision support tool for families of patients with critical illness: A multicenter pilot study

May 1, 2017

Journal of Pain and Symptom Management, Volume 53 – Issue 5: Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel

April 1, 2017

Journal of Pain and Symptom Management, Volume 53 – Issue 4: Measuring Advance Care Planning: Optimizing the Advance Care Planning Engagement Survey

September, 2016

Critical Care Medicine, Volume 44 – Issue 9: Predicting Performance Status 1 Year After Critical Illness in Patients 80 Years or Older: Development of a Multivariable Clinical Prediction Model

August 17, 2016

BMJ Quality & Safety: The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study

April, 2015

JAMA Intern Medicine, Volume 175 – Issue 4: Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians

To live well, age well, and die well, you need to Plan Well