1. Serious Illness Communication Skills Training

Clinical groups that have elected to work with our team participate in small-group, interactive communication skills training. During these 3-hour sessions, clinicians learn how to conduct advance care planning (ACP) discussions using the Serious Illness Conversation Guide. For more information, visit our Clinician Training page.

2. Clinical Workflow Redesign

We work with each clinical group to develop criteria to identify their patients who would most benefit from an ACP conversation; these criteria vary by clinical specialty. When appropriate, an implementation may leverage validated machine learning models to assist with patient identification. We collaborate with clincians to integrate a five-step process into their workflow, resulting in a customized communication framework.

3. System-Wide EMR Documentation

Clinicians use an Epic SmartForm developed by Dr. Teuteberg and SHC’s Epic team for standardized documentation of ACP conversations. This SmartForm can be accessed throughout Stanford Medicine and by all care team members. Visit Documenting in Epic for step-by-step instructions.


Li, Ron C., et al. “Using AI to Empower Collaborative Team Workflows: Two Implementations for Advance Care Planning and Care Escalation.” NEJM Catalyst, vol. 3, no. 4, Mar. 2022. (Crossref),

Gensheimer, Michael F., et al. “Use of Machine Learning and Lay Care Coaches to Increase Advance Care Planning Conversations for Patients With Metastatic Cancer.” JCO Oncology Practice, vol. 19, no. 2, Feb. 2023, pp. e176–84. (Crossref),