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:
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.
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.
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 PlanWellGuide.com 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.
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.
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.
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.
If you wish to play any of our videos on a TV/ computer in your waiting or exam room, please contact us.
Available in French and English, for individual use and for ordering in bulk from print shops.
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
This Guide provides a framework including scripts to assist you with engaging patients and/or their Representatives in goals of care (GOC) conversations
A downloadable prescription pad gives you a convenient way to encourage your patients to visit the Plan Well website
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.
Aging Clinical and Experimental Research (2021): Challenges and facilitators in delivering optimal care at the End of Life for older patients: a scoping review on the clinicians’ perspective
Journal of General Internal Medicine (2021): Randomized Controlled Trial of a Decision Support Intervention About Cardiopulmonary Resuscitation for Hospitalized Patients Who Have a High Risk of Death
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
ICU Management & Practice, Volume 20 – Issue 3: Unmasking the Triumphs, Tragedies, and Opportunities of the COVID-19 Pandemic
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
The Royal College of Physicians and Surgeons of Canada: New tool helps patients plan for serious illness care
Healthcare, MDPI, Volume 8 – Issue 3: Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)
Ontario Hospital Association: Supporting Patients in Getting the Medical Care that Is Right for Them
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
Canadian Medical Protective Association Practically Speaking Podcast: COVID-19: Advance care directives
BMC Family Practice, Volume 21- Number 94: Exploring patient-reported barriers to advance care planning in family practice
Canadian Hospice Palliative Care Association: Become a CHPCA Associate or Affiliate / Provincial Member
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
Canadian Medical Association Journal, Volume 8 – Issue 2: A novel decision aid to help plan for serious illness: a multisite randomized trial
The Annals of Family Medicine, Volume 18 – Issue 2: Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings
The Lancet: EClinicalMedicine, Volume 19: Advance care planning; we need to do it more, but it needs to be done differently
Journal of Pain and Symptom Management, Volume 58 – Issue 6: Brief English and Spanish Survey Detects Change in Response to Advance Care Planning Interventions
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
Canadian Medical Association Journal, Volume 7 – Issue 4: Supporting shared decision-making about cardiopulmonary resuscitation using a video-based decision-support intervention in a hospital setting: a multisite before–after pilot study
BMJ Supportive & Palliative Care: Evidence of increasing public participation in advance care planning: a comparison of polls in Alberta between 2007 and 2013
Journal of Pain and Symptom Management, Volume 57 – Issue 5: Adaptation and Preliminary Validation of the Advance Care Planning Engagement Survey for Surrogate Decision Makers
BMJ Supportive & Palliative Care: Patient-family agreement on values and preferences for life-sustaining treatment: results of a multicentre observational study
BMJ Supportive & Palliative Care Published Online First: Short Graphic Values History Tool for decision making during serious illness
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
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
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
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