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He completed 21 of 30 passes while also running 13 times, his one yard TD at 9:44 of the fourth buy runescape gold snapping a 23 23 tie. I have had no instructions since so I stay at Plymouth.". If required a substitute decision maker (surrogate) is nominated.12 13 The potential barriers to advance care planning include the availability of trained staff with the time, competence, and confidence to discuss advance care planning with patients; organisational commitment and policy to support advance care planning; and ensuring that doctors understand and support advance care planning.14 15 16 Carrying out effective advance care planning in elderly patients is challenging, especially when they are acutely unwell and have a short length of stay in hospital before discharge.Much of the focus on advance care planning has been on improving the completion rate of advance directives.16 17 Such improvement does not necessarily improve medical care1 16 18 or end of life care.1 19 Models of advance care planning such as the Respecting Choices programme have shown that a coordinated, systematic, patient centred approach to advance care planning by trained non medical facilitators can improve outcomes for patients.13 20 21 22 Evidence also shows that advance care planning and end of life discussions reduce stress, anxiety, and depression in surviving relatives.23 24 25 26Although completion of a physician orders for life sustaining treatment has been shown to improve end of life care in nursing home residents,27 no randomised controlled trials have investigated whether advance care planning improves end of life care.

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