Yearly Checklist: Updating Advance Care Planning Skills as a Resident

The worst residents to work with are the ones who never update how they talk about death.

The Annual Cycle: One Year of Keeping Your ACP Skills Sharp

You’re not going to “master” advance care planning (ACP) in one ethics lecture and a single goals‑of‑care note. ACP skills decay. Laws change. Your own comfort level shifts as you see more bad deaths and more good ones.

So treat ACP like a procedure. It needs:

• A yearly refresh
• Periodic drills
• Real‑time debriefs

Here’s a concrete, time‑structured plan you can repeat every academic year.

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July–August: Baseline Reset and Legal Reality Check

At this point in the year you’re onboarding, adjusting to a new level of responsibility, and meeting new attendings. Perfect time for a reset.

Week 1–2: Quick Legal and Policy Update

Spend 60–90 minutes getting current. Not optional.

1. Confirm state law basics
   Look up your hospital or GME’s “Advance Directives” or “Goals of Care” policy and your state legal guidance. Focus on:

   • Who can be a surrogate and in what order of priority
   • Requirements for a valid advance directive
   • State‑specific POLST/MOLST forms (if applicable)
   • Capacity vs competence (your role vs the court’s)
   • DNR/DNI vs “comfort measures only” vs “limited interventions”

2. Clarify your documentation responsibilities
   Find and read:

   • The template for goals‑of‑care notes
   • Code status documentation rules
   • Where ACP documents live in the EHR (media tab? ACP tab? Scanned?)

You’re aiming for this standard: by the end of August, you should be able to find any patient’s signed ACP documents in under 60 seconds.

Concept	Your Task Each Year
Surrogate hierarchy	Re‑confirm state‑specific order and exceptions
Advance directive rules	Review validity requirements and scope
POLST/MOLST	Check latest state form and indications
Code status definitions	Confirm local wording and order set options
Capacity assessment	Revisit institutional policy and tools

Week 3–4: Self‑Assessment and Skill Targeting

Now you figure out where you actually suck.

Do a 10‑minute self‑audit: Rate yourself 1–5 (1 = awful, 5 = strong) on:

• Explaining code status in plain language
• Eliciting values (not just procedures)
• Handling conflict between family members
• Recognizing and documenting lack of capacity
• Knowing when to call ethics / palliative care

Anywhere you’re ≤3 becomes a deliberate focus for the year.

At this point you should:

• Know your state’s basic ACP laws cold
• Know exactly where to click in the EHR to find ACP docs
• Have 2–3 specific skills you’re targeting this year

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September–October: Build Technique, Not Just Vocabulary

Now you move from “I know the terms” to “I can run the conversation without freezing.”

September: Structured Learning Sprints

Pick two 30–45 minute blocks this month. Treat them like procedures labs.

1. Sprint 1 – Conversation structure Review or create a simple framework you’ll actually use. For example:

   • Opening: “I talk with all my patients about what matters to them if they get very sick…”
   • Check understanding of illness
   • Explore values: function, independence, suffering, family roles, longevity
   • Make a recommendation tied to those values
   • Summarize and confirm

   Write your version out. Literally. Three to five bullet points on a personal “ACP cheat sheet” you can keep in your pocket or Notes app.

2. Sprint 2 – Language upgrades Replace bad phrases with better ones. For instance:

   • Instead of “Do you want us to do everything?” →
     “If your heart were to stop, would you want us to use chest compressions and life support machines, knowing they may not help you get back to the kind of life you’d want?”
   • Instead of “You’re a DNR, right?” →
     “I want to revisit what we would do if your heart stopped or you stopped breathing, so our plan matches what matters most to you.”

   Draft 5–10 go‑to sentences. You’ll use them daily.

October: Practice on Real Encounters (With a System)

Now you attach practice to real work.

For the month of October, set a simple rule:

• Rule: On every admitting shift, pick one appropriate patient and do a 5–10 minute values‑focused ACP conversation (not just “what’s your code status?”).

After each:

• Jot 3 bullets:
  • What worked
  • What felt awkward
  • What you want to say differently next time

This reflection should take under 2 minutes. If it’s longer, you won’t do it.

At this point you should:

• Have a repeatable script structure you can adapt
• Be using at least a few improved phrases daily
• Be doing intentional ACP practice with at least 1–2 patients per call or clinic session

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November–December: Integrate Ethics and Handle the Hard Cases

By late fall, you’ve seen some mess: estranged families, unrealistic expectations, maybe outright legal threats. Time to sharpen the ethics side.

November: Tough Scenario Rehearsal

One evening or weekend this month, do a focused 45–60 minute session. Pull 3–4 cases from your recent rotations where ACP went sideways. For each, answer:

• What was the actual ethical tension?
  (Autonomy vs best interest? Surrogate disagreement? Futility vs family demand?)
• Where did you feel stuck?
• What would you try differently next time?

Then, rehearse out loud. Yes, out loud. Residents who only “think about” these lines never get smooth.

Practice things like:

• “Medically, this treatment will not help your father get back to any quality of life he would recognize. Continuing it would not be in line with what you told me matters to him.”
• “You’re asking for us to do something that we believe will cause him more suffering without benefit. Ethically and medically, that’s not something we can offer.”

December: Know When and How to Escalate

December is for accepting you’re not the ethics hero of the hospital. You need backup.

Clarify:

• How to page or refer to:
  • Palliative care
  • Ethics consultation
  • Risk management (when legal threats appear)
• What triggers you personally will use to call them:
  • Surrogates in open conflict
  • Demands for clearly non‑beneficial care
  • Suspected undue influence or abuse
  • Confusion about who is the legal decision maker

Write yourself a one‑line rule:

• “If I have more than 2 family meetings about the same conflict with no movement, I loop in ethics/palliative.”
• Or whatever threshold makes sense at your institution.

At this point you should:

• Have practiced language for ethically messy conversations
• Know exactly how to activate ethics/palliative consultation without hesitation
• Have at least one senior/attending you trust to debrief hard ACP cases with

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January–February: Documentation, Capacity, and Legal Precision

New year, same patient charts full of vague, useless notes. Fix that.

January: Documentation Boot Camp (1–2 Weeks)

For two weeks:

• Every day, pick one ACP or goals‑of‑care note and critique it.
  Yours or someone else’s.

Ask:

• Does it clearly state:
  • Who was present?
  • What the patient’s understanding is?
  • What their values are (in their own words if possible)?
  • What specific decisions were made (or deferred)?
  • The plan for revisiting?

Rewrite at least two of your own notes to a higher standard. You’re training your future self (and your colleagues) to understand what actually happened.

Aim for notes that read like this (stripped example):

“Pt states, ‘If I can’t recognize my family or do anything for myself, I don’t want to be kept alive on machines.’ We discussed that CPR and intubation are unlikely to return him to independent function if he has another major event. He prefers comfort‑focused care and would not want CPR or intubation. Code status updated to DNR/DNI, daughter Jane Doe listed as primary surrogate.”

Not:

“Discussed goals of care. Code status DNR/DNI.”

February: Capacity Assessment Refresh

ACP is meaningless if you misjudge capacity.

This month:

• Re‑read your institution’s policy on capacity
• Review a simple checklist or tool (e.g., understanding, appreciation, reasoning, ability to communicate a choice)
• Identify how your team documents capacity in ACP notes

Build yourself a 4‑question mental checklist:

• Can they state the problem in their own words?
• Can they recognize the likely outcomes of options?
• Can they compare options based on their values?
• Can they communicate a consistent choice?

If any of those fail, your ACP conversation shifts:

• Focus more on surrogate decision making
• Document your capacity concern explicitly
• Consider psych consult if there’s diagnostic uncertainty or reversible factors

At this point you should:

• Be writing ACP notes that future teams can actually use
• Be more deliberate and explicit in how you assess and document capacity
• Be more comfortable saying, “I do not think this patient has decision‑making capacity for this choice today, because…”

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March–April: Teach, Lead, and Systematize

If you’re mid‑ or senior‑level, this is where you stop being the learner only and start enforcing better habits across your team.

March: Micro‑Teaching on Rounds

Pick one ACP micro‑topic per week to teach interns/med students for 3–5 minutes on rounds or at a break:

• Week 1: How to open a goals‑of‑care conversation without freaking everyone out
• Week 2: How to explain DNR/DNI without using jargon
• Week 3: How to document values, not just decisions
• Week 4: Basics of your state’s surrogate decision‑maker hierarchy

Use an actual patient on the list as an example. “For Mr X, here’s how I’d start that conversation…”

Why this matters: teaching forces you to clarify your own thinking and language. And frankly, it raises the floor for everyone.

April: Lead at Least One Family Meeting Properly

By this point in the year, you should deliberately volunteer to lead at least one structured family meeting focusing on ACP/goals of care, with an attending present.

Before the meeting:

• Draft a 3‑line agenda:
  • “Review where things stand medically”
  • “Understand what matters most to the patient”
  • “Make a plan that fits those priorities”

During:

• Introduce everyone
• State the agenda out loud
• Use your practiced language and framework
• Summarize clearly at the end and assign who will document

After:

• Ask your attending for specific feedback:
  • Clarity?
  • Empathy?
  • Time management?
  • Ethical framing?

At this point you should:

• Be comfortable giving quick ACP teaching points to juniors
• Have run at least one formal family ACP meeting with supervision
• Be getting more intentional, targeted feedback on your communication style

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May–June: Reflection, Metrics, and Next‑Year Upgrades

You’re closing out the year. This is where you stop and take stock rather than just rolling into the next PGY level exactly the same.

May: Personal ACP Audit

Set aside 30–45 minutes. Pull 5–10 charts from earlier in the year and 5–10 recent charts where you were involved in ACP or code‑status decisions.

Compare:

• Is your language clearer?
• Are values more explicitly documented?
• Are surrogates clearly identified?
• Did you more often call ethics/palliative when needed?
• Are there fewer vague “discussed GOC” notes and more concrete summaries?

Resident ACP Practice Improvement Over the Year

Category	Value
Early Year	2
Mid Year	4
Late Year	7

(Example: number of clearly documented value‑based ACP notes in 3 sampled periods.)

Extract 3 lessons:

• One communication habit you want to keep
• One documentation habit you want to keep
• One pattern you still dislike in your own charts or behavior

Write them down. Literally. This becomes your PGY‑to‑PGY handoff… to yourself.

June: Set Next‑Year Targets and Shore Up Gaps

By June you know what rotation is coming first next year (ICU, wards, clinic, etc.). Customize your ACP plan to that context.

Examples:

• Going into ICU:
  • Target higher‑stakes family conferences, non‑beneficial treatment conversations, and explaining prognosis with uncertainty.
• Going into outpatient primary care:
  • Focus on earlier ACP, chronic illness trajectories, advanced directives and POLST completion.

Take 20 minutes to define 2–3 concrete goals for next year:

• “Lead 3 ICU‑level family meetings with attending feedback”
• “Consistently screen for ACP on all new ≥65 year‑old clinic patients”
• “Present 1 brief teaching session on state ACP law for interns”

Capture them in a simple text file or note labeled:
“ACP Goals – PGY X”

At this point you should:

• Have a realistic picture of how your ACP skills changed this year
• Have 2–3 defined, written goals for next year tied to your rotations
• Feel less dread and more structure around these conversations

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Daily and Weekly Micro‑Checks (All Year)

Sprinkled across the year, you keep skills from decaying with small habits.

Weekly: 10‑Minute ACP Review

Once a week, at a predictable time (end of call week, Friday afternoon, etc.):

Ask yourself:

• Did I avoid an ACP conversation I should’ve had?
• Did I have one that went especially well or badly?
• Did I document at least one patient’s values in their own words?

Pick one case and do a 3‑line mental or written debrief:

• What triggered the conversation?
• What I said that worked or didn’t
• One sentence I’ll use differently next time

Daily (or Almost Daily): Micro‑Behavior

On most inpatient days, aim for:

• 1 patient where you go beyond the yes/no code status checkbox
• 1 note where you add at least one direct quote about values

Yearly ACP Skill Maintenance Timeline

Period	Event
Summer - Jul-Aug	Legal refresh, EHR workflow, self-assessment
Fall - Sep-Oct	Script building, routine ACP practice
Fall - Nov-Dec	Ethics focus, escalation patterns
Winter - Jan-Feb	Documentation and capacity refresh
Spring - Mar-Apr	Teaching and leading family meetings
Spring - May-Jun	Audit, reflection, next-year goals

Over time, that becomes muscle memory.

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Core Takeaways

• Treat advance care planning like a procedure: it needs yearly refresh, deliberate practice, and post‑case debriefs, not just “one good lecture.”
• Anchor your growth to the calendar: summer for legal and system basics, fall for scripts and reps, winter for documentation and capacity, spring for teaching and leadership.
• Measure your progress in specifics: clearer notes, faster access to ACP documents, more value‑based conversations, and better use of ethics and palliative resources when cases get hard.