Advance Care Planning Across Care Transitions and Complex Family Situations

Advance care planning becomes most challenging when patients move across settings, when family dynamics are complex, and when ethical tensions arise. This applied course teaches structured approaches to those situations. By the end of this course you will be able to coordinate ACP across care transitions, manage family dynamics during ACP discussions, navigate ethically challenging situations, and integrate ACP into team-based care. What you will learn: - Frameworks for coordinating ACP across hospital, primary care, long-term care, and home settings - Approaches to family dynamics including conflict between surrogate and patient wishes - Approaches to discussions in cognitive impairment including reduced decision capacity - Ethical frameworks for situations involving disagreement among surrogates - Approaches to ACP in patients with chronic serious illness over time - Approaches to ACP in pediatric and adolescent populations within scope - Integration of ACP into multidisciplinary team workflows and electronic records The course is structured around case-based applied modules. Each module presents a complex scenario, walks through structured reasoning, and produces a written approach you compare against the worked-through example. This course is written for clinicians, nurses, social workers, chaplains, and ethicists working with patients facing serious illness. It does not replace agency-specific policies or ethics consultation. By the end you will have structured frameworks for handling complex ACP situations and for integrating ACP into team-based care across settings.