Tell us about that and the process.

Anytime someone is very sick, whether that is an acute illness, say pneumonia or an infection or sepsis, or whether that is a dramatic shift in a chronic condition, perhaps the person has heart failure and is having an exacerbation, or maybe it is something like cancer or something that is progressing in that way.

The advanced care planning documents come into play when that person can no longer communicate their own wishes in the moment.

So if a patient can understand the treatment plan, participate in conversations and tell me what they want, that rules.

That's it.

At the point when they can no longer participate in those conversations is when the advanced care planning information kicks in.

So I talked about three different documents.

Have you ever come across a case where the advanced care plan says one thing, but the patient's family really feels strongly in a different way about things? And if so, what happens in that situation? How do you navigate that?