Complete a health care proxy
Everyone in Massachusetts, 18 or older, has designated a health care decision-maker (known as a health care "agent").
Engage in ongoing conversations with your health care agent
Everyone in Massachusetts, 18 or older, has had a conversation (and continues to have conversations) with their agent to communicate their goals, values and preferences for care at the end of life.
Ensure appropriate training for clinicians
All Massachusetts clinicians have appropriate training to facilitate high-quality communication with patients on advance care planning and serious illness.
Have an informed conversation with your care team
Everyone in Massachusetts facing a serious illness has had a high-quality, informed goals and values conversation with their care team.
Create a system to elicit and document wishes
All Massachusetts health care providers have systems in place to elicit and document goals, values, and preferences for patients with serious illness.
Ensure that preferences can be shared, regardless of place of care
All Massachusetts health care providers have systems in place to share patient goals, values and preferences across care settings, to ensure they are accessible regardless of place of care.