From Checklists to Care Plans: How Facilitation Unlocks Digital Directives

Digital tools are good. Guided digital tools are transformational.

By Jim Kraft, Ph.D.
CEO, Advance Care Associates
ACP Trainer & Certified Facilitator

Digital technology has made advance directives more accessible than ever—but when patients are left to navigate those forms on their own, the process often falls short. Clicking through legal language in a portal doesn’t automatically translate into clear, actionable care preferences. For many patients, it can feel sterile, confusing, and incomplete.

Facilitated advance care planning (ACP) offers a better way. When a trained professional guides the conversation, patients feel supported, heard, and better prepared to make meaningful decisions. And when those decisions are captured in a secure, digital platform like MyDirectives for Clinicians (MyDC), they become more than preferences—they become clinical tools.

In this blog, we explore how combining human facilitation with digital ACP platforms leads to stronger care plans, better documentation, and greater peace of mind for everyone involved.

The Problem with Going It Alone

Self-guided ACP tools may be convenient—but they often miss the mark in capturing what truly matters.

Patients are expected to navigate unfamiliar medical language, make high-stakes decisions, and articulate deeply personal values—all without any human interaction. The result?

• Low health literacy makes legal terms like “artificial nutrition and hydration” confusing.
• Patients frequently skip the “values” section, even though clinicians look for these when delivering care.
• Forms rarely prompt users to discuss their wishes with family or name a surrogate decision-maker.

Even when a directive is technically complete, it may not be clinically useful. It may lack clarity, specificity, or legal validity. Documents get lost. Boxes get checked without context. Family members remain unprepared.

Ultimately, a poorly executed directive can create the very confusion and conflict it was meant to avoid—leaving care teams to guess and families to struggle.

That’s why the industry is moving toward facilitated, person-centered ACP—a model that combines the guidance of a skilled facilitator with the accessibility of digital tools.

What a Facilitator Brings to the Table

Facilitated ACP isn’t about taking choices away from the patient—it’s about making sure they’re understood, explored, and documented with compassion and clarity.

How facilitation changes the game:

• Empathetic listening allows facilitators to hear what the patient is trying to say—even when they don’t have the perfect words. This brings to light cultural, spiritual, and emotional concerns that paper forms often miss.
• Storytelling and metaphors help patients express themselves. For instance, “I don’t want to be kept alive by machines” becomes “If there’s no meaningful recovery, I would decline ventilator support.”
• Real-time coaching encourages patients to reflect more deeply and, when using MyDC, add personal video or audio messages to clarify their wishes.

Facilitators also bring structure to the conversation. They explain key concepts, help define what’s acceptable or unacceptable based on personal values, and ensure patients know how their choices will impact their care.

And because facilitators are trained to recognize nuances in communication, they can help resolve hesitations that might otherwise result in incomplete or inaccurate directives.

“Facilitators translate emotions into clinically actionable decisions. They bridge the gap between human values and medical protocols.” - Dr. Imad Mansoor, Michigan-based Internist

This process not only empowers the patient—it also gives clinicians and families the confidence to act in alignment with the patient’s voice.

Making Digital Better

Facilitators bring clarity to the conversation. MyDirectives® ensures that clarity is captured, shared, and accessible at the moment it’s needed most.

Here’s how facilitation enhances the clinical value of a digital directive:

Without this integration, even the best conversation can fall flat. But with structured data fields, cloud storage, and interoperability, MyDC turns a personal conversation into an actionable medical record—legally compliant, audit-ready, and always up to date.

Together, facilitation + digital technology = high-fidelity ACP.

Actionable Takeaways

Whether you’re a provider, administrator, or advocate, here’s how to make advance care planning more impactful:

If you're a provider:

Offer a facilitated ACP session by default when a patient begins a digital directive. Let someone trained lead the conversation while you focus on care.

If you're in administration:

Embed ACP summaries into your workflow—EHR notes, morning huddles, care team briefings. They offer rich context that improves quality metrics and outcomes.

If you're a patient advocate:

Ask for facilitated ACP—especially for patients over 65 or with serious illness. It’s worth the time, and it helps reduce stress during medical emergencies.

Tools to Consider:

• MyDirectives for Clinicians – Secure, cloud-based ACP platform with video, text, embedded facilitator guidance, and structured fields for capturing key decisions.
• Five Wishes – A values-first, complete advance directive. MyDirectives is the exclusive digital partner, integrating Five Wishes into MyDC while also supporting upload of completed paper forms. A separate digital option also exists on FiveWishes.org.
• Portable Medical Orders/POLST – For patients with advanced illness who need portable medical orders alongside an ACP. MyDC includes embedded national and state-specific POLST forms with guidance for simple form completion.

When done well, ACP becomes more than a form—it becomes an enduring statement of dignity, choice, and trust.

From Documentation to Transformation

Facilitated ACP transforms a transactional process into a transformational one. When patients are supported by trained facilitators and their wishes are documented using digital tools like MyDC, they gain confidence—and clinicians gain clarity.

This hybrid approach ensures that ACP is not only done, but done well.

✔ The conversation is human.
✔ The documentation is digital.
✔ The care is aligned.

It’s how we move from checklists to care plans. From fear to peace. From confusion to confidence.

About the Author

Jim Kraft, Ph.D. is Founder and CEO of Advance Care Associates, a national organization dedicated to helping individuals and families navigate advance care planning through values-driven conversation and compassionate guidance. With more than two decades of experience, Jim is a nationally recognized educator and advocate for person-centered care. Advance Care Associates is a strategic partner with MyDirectives, working together to expand access to scalable, digital advance care planning nationwide.