Advance Care Planning Toolkit

Written By Lisa Fleetwood
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Why It Matters

Faith Community Nurses and health ministry leaders are uniquely positioned to help members of their communities and congregations think about advance care planning in a meaningful, values-centered way. While many people find it difficult to think about or discuss their final days, FCNs can reframe these conversations as a natural part of life that everyone will experience. They give individuals space to consider how the experience could or should unfold, address important personal or relational issues such as forgiveness or reconciliation, and reflect on what truly matters. FCNs help families have open conversations about both the practical and spiritual aspects of the dying experience, and in doing so, they bring an aspect of holiness and honor into someone’s final days. They also play a vital role in addressing health disparities, ensuring that all members of the community have the opportunity to reflect, plan, and approach the end of life with dignity and peace.

Quick Advance Care Planning Fast Facts

  • Most adults do not have an advance directive. Only about 37 percent of U.S. adults have completed a living will or health care proxy. (NIH/NIA)

  • Most people want to die at home, but few do. About 80 percent of Americans would prefer to spend their final days at home, yet only 20–30 percent actually do. (ACP Decisions)

  • Advance directives increase the chance of care aligning with your wishes. People with advance directives are more likely to receive care consistent with their values and avoid unwanted aggressive treatment. (CHA USA)

  • Many adults lose the ability to make decisions before death. Nearly 30 percent of older adults need a surrogate decision maker near the end of life, making advance directives critical. (CHA USA)

  • Advance directives can influence where people die. Those with advance directives are more likely to die in their preferred setting, including at home, and to participate in hospice care. (PubMed)

Faith Community Nurses can make a real difference in promoting advanced care planning. FCNs are uniquely equipped to:

  • Guide members in clarifying personal values and wishes, integrating their spiritual beliefs and faith perspectives into advance care planning.

  • Understand and honor the values and traditions of their community, helping conversations about end-of-life care feel culturally and spiritually respectful.

  • Partner with faith leaders, clergy, or pastoral support to ensure holistic guidance and continuity between medical planning and spiritual care.

  • Leverage long-standing, multi-generational relationships within the faith community to connect with families at every stage of life.

  • Create a safe, compassionate space for open discussion about sensitive topics, allowing members to reflect, ask questions, and consider their preferences.

  • Support families in preparing for meaningful, value-centered end-of-life experiences, helping reduce disparities in access to information and guidance.

assignment

Ready-to-Use Program Ideas

  • Objective:
    The Faith Community Nurse will create a Death Cafe–style gathering that invites participants to openly discuss the dying experience, reflect on personal values and relationships, and consider how advance care planning can support meaningful, well-prepared end-of-life experiences.

    Metric:
    At least (input your number) community members will participate in the Death Cafe–style conversation, and at least (input your number) participants will identify one reflection, question, or next step related to the dying experience or advance care planning, such as talking with family or learning more about advance directives.

    Data Collection Tool: End of Life Conversation Participation and Reflection Tracker

    Key Activities (Creative Implementation Ideas):

    Death Cafe Conversation Gathering:
    Host a facilitated, informal gathering in a comfortable space with seating arranged in a circle or small groups. Clearly explain that the purpose is conversation and reflection, not teaching or completing forms. Establish simple guidelines for respectful listening and confidentiality.

    Conversation Starters and Reflection Prompts:
    Use open-ended prompts to invite discussion, such as:
    What experiences have shaped how you think about dying
    What matters most to you at the end of life
    What do you wish families talked about sooner
    Who would you trust to speak for you if you could not

    Facilitation and Support:
    Invite a faith leader, chaplain, hospice professional, or trained volunteer to be present alongside the Faith Community Nurse to support conversation and respond to emotional or spiritual needs as they arise. Use this facilitator’s guide as a resource.

    Values Clarification Activity:
    Offer a brief written or verbal reflection that helps participants identify what gives their life meaning, what brings comfort, and what they would want others to know about their wishes. Use this Values Clarification guide as a resource.

    Resource Table for Optional Next Steps:
    Provide take-home materials on advance care planning, health care decision makers, and conversation guides for families. Make resources available without pressure to act immediately. Use the Conversation Starter Project Guide as a resource.

    Closing Reflection:
    End the gathering with a moment of quiet reflection, shared gratitude, or silence to honor the stories and experiences shared. Sample Closing Reflection

    Follow-Up Invitation:
    Invite participants to schedule a one-on-one conversation with the Faith Community Nurse or attend a future session focused specifically on advance directives.

    Other Resources to Support This Goal:

  • Objective:
    The Faith Community Nurse will plan and facilitate an advance care planning conversation circle that supports spiritual and emotional reflection, provides practical resources, and invites participants to explore personal values and next steps in advance care planning.

    Metric:
    At least (insert number) community members will participate in the conversation circle, and at least (insert number) participants will identify one next step toward advance care planning (e.g., talking with family, exploring values, obtaining resources).

    Data Collection Tool:
    End of Life Conversation Participation and Reflection Tracker

    Key Activities (Creative Implementation Ideas):

    Preparation and Setting:
    Choose a welcoming space with seating in a circle to promote equality and connection. Prepare simple refreshments and a brief handout with helpful links to advance care planning tools. Begin with a brief welcome and explanation that the circle is for sharing and reflection rather than instruction or paperwork.

    Use these resources to prepare for this activity.

    Printable Reflective Worksheets:

    Conversation Guides and Practical Planning Sheets:

    Advance Directive Forms (Legal Documents):

    Conversation Starters and Reflection Prompts:
    Use open-ended questions to invite sharing and reflection, such as “What gives your life meaning?” or “What hopes or concerns do you have about future care?” Allow participants time to reflect aloud or in pairs.

    • Conversation Starter Guides (The Conversation Project) — helpful downloadable tools such as “Your Conversation Starter Guide” and “Guide to Choosing a Health Care Proxy” that participants can reflect on and bring into dialogue. The Conversation Project Guides

    Facilitation and Emotional Support:
    Co-facilitate, if possible, with a faith leader, chaplain, or trained volunteer who can help hold the space and offer spiritual or emotional support. Encourage active listening, validation, and respect for silence or varied comfort levels.

    • Use this resource to help identify a co-host for your event.

    Values Clarification Activity:
    Provide a simple reflection prompt or worksheet to help participants think about what matters most to them in life and care preferences.

    • Advance Care Planning Values Worksheet (PDF) — helps individuals think through what matters most to them, including quality of life and care preferences. Advance Care Planning Values Worksheet

    Advance Care Planning Resources:
    Provide a resource table or handout with links such as:

    Opening and Closing Reflections:
    Begin with a moment of prayer, meditation, or silence to center the group. Close with gratitude and a brief reflective prompt such as “One insight I will take forward…” to honor shared stories.

    Follow-Up Invitation:
    Invite participants to schedule a one-on-one follow-up with the Faith Community Nurse or to join future sessions for deeper exploration or help completing advance directives.

    Tip: After the circle, provide a follow-up handout or email listing the shared resources with a brief explanation of how each can support participants’ next steps in advance care planning.

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Ready-to-Share Videos

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Focus on Spiritual Integration

Emotional Support

Advanced care planning can be a challenging topic for many congregants, often bringing up fear, anxiety, or memories of past negative experiences. As a Faith Community Nurse, providing emotional support is a vital form of spiritual care. By creating a safe, nonjudgmental space, listening actively, and validating emotions, you honor both the person’s feelings and their spiritual well-being. Emotional support allows individuals to explore what matters most in their lives, reflect on their values, and find reassurance rooted in their faith or sense of purpose. For those who are hesitant or fearful, simply acknowledging their discomfort, offering empathy, and letting them know support is available whenever they are ready is itself a spiritual act. Respecting boundaries—sometimes planting the seed for a future conversation or offering resources—is another way to honor their emotional and spiritual journey.

Practical ways to provide this support include beginning conversations with open-ended questions such as, “What gives you strength in challenging times?” or “What matters most to you as you think about the future?” Offer gentle reassurance that thinking about advanced care planning does not mean immediate action is required, and remind congregants they can revisit the topic at their own pace. Reflective listening—repeating or summarizing what they share—helps them feel heard and understood. You can also suggest small, faith-based practices that provide comfort, such as prayer, meditation, or discussion with a trusted spiritual leader.

Tip: Keep a list of local or congregational resources for emotional and spiritual support that you can offer proactively, so congregants know help is available when they are ready. By integrating these approaches, Faith Community Nurses help congregants navigate advanced care planning in a way that supports both their emotional and spiritual well-being, making the process less intimidating and more meaningful.

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The resources provided on this website are for informational and educational purposes only. They are not intended to replace professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The Indiana Center for Parish Nursing (ICPN) does not endorse or guarantee the accuracy of information from external websites linked here.

Lisa Fleetwood
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