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Helping You Help Our Patients

We encourage our valued providers and healthcare partners to take advantage of these resources to help you guide and support advance care planning discussions with your teams and patients.

Please Note

The external websites linked to from this webpage contain the information and viewpoints approved by those organizations. While we do believe these websites contain valuable resources that may be useful to you, these links do not represent an official endorsement of any other organizations' materials by Inova Health System.

Ascertaining and understanding a patient’s wishes is an important component of high-quality care. Clinicians should always ensure patients receive care that aligns with their values and goals. With the new reality of the COVID-19 pandemic, the importance of providing goal-concordant care has become heightened. Now more than ever, it is crucial for people to have these important personal conversations with their healthcare providers and families and to make decisions prior to the possible development of serious acute illness.

As medical providers, the types of conversation you may have with your patient about health care goals and wishes will vary based on your patients’ current condition and location of care. 

The palliative care and geriatric teams, along with medicine leadership at Inova have compiled this list of resources to help you guide your patients in expressing their healthcare wishes, verbally and in writing.

What is Advance Care Planning?

Advance care planning is the process of planning for future medical care, particularly for the event when the patient is unable to make his or her own decisions. It may also help relieve family members and physicians of their concerns in making difficult decisions during challenging moments. It should be a routine part of standard medical care. It may include advance directive documents such as a living will, power of attorney for healthcare decisions or healthcare agent.

Why Is It Important?

An advance directive allows a person to document or verbally state to healthcare professionals and family in advance what their wishes are before that individual is unable to make decisions at the end of life.

It is okay to feel uncomfortable to speak with a patient about final wishes. Just remember that if there is no written document or discussion ahead of time then no one will know how the patient would like to be treated. Each patient conversation flows differently and being aware of available resources in different stages of the discussion will empower you moving forward in helping patients and their family members.

Advance Care Planning – Community and Post-Acute Partners (e.g., Assisted Living Facility, Home Health, Hospice, Skilled-Nursing Facility)

What documents are part of ACP?

ACP includes several documents:

  • An advance directive and living will – a written document stating a patient’s wishes about healthcare decisions in the event the patient becomes unable to make healthcare decisions in the future.
  • A durable do not resuscitate (DDNR), physician’s orders of scope of treatment (POST) or equivalent form – a signed medical order for specific healthcare to be provided to, or withheld from, a patient in the event of a medical emergency, such as cardiac arrest.
  • A guardianship or custody document – a court document granting decision-making authority to a guardian or custodian for a patient deemed legally incompetent.
  • Learn More About Advance Care Planning Document Types

Who can have ACP conversations?

An ACP conversation can be started by any member of your care team or support network (e.g., family members, neighbors, friends). Several disciplines can bill for these conversations.

  • Surrogate – an adult authorized by Virginia statute to make medical decisions for a decisonally incapacitated patient when there is no applicable advance directive or appointed agent.
  • A power of attorney – an adult legally appointed by the individual in an advance directive to make healthcare decisions in the event of the individual's decisional incapacity. The PoA is also known as medical power of attorney, agent, or healthcare agent.

How do I access my patients' ACP documents on file at Inova?

EpicCare Link is a free, enhanced read-only application offering community providers secure, remote access to view their patients' Inova medical records. Learn more

How do I share my patients' documents with Inova?

It is important for Inova to have a copy of your patients’ most recent ACP documents as soon as they are available. Fax them to us at 571-472-6505 or email to

What training and educational resources are available?

Additional Educational Resources:

Advance Care Planning – Primary and Specialty Care

Goals of Care – Hospital Resources