Clinical meaning
Advance care planning (ACP) is a process rooted in the bioethical principles of autonomy (patient self-determination), beneficence (acting in the patient's best interest), non-maleficence (avoiding harm), and justice (equitable resource allocation). The ethical framework for goals-of-care conversations is built on the concept of informed consent, which requires that a patient with decision-making capacity receives adequate information about their diagnosis, prognosis, treatment options (including the option of no treatment), and the benefits, risks, and burdens of each option. Decision-making capacity is distinct from legal competence and is assessed along four dimensions: the ability to understand relevant information, appreciate how it applies to one's own situation, reason about the options using consistent values, and communicate a choice. Capacity is decision-specific (a patient may have capacity for simple decisions but not complex ones) and may fluctuate with delirium, medication effects, or disease progression. When a patient lacks capacity, the substitute decision-maker (SDM) must apply substituted judgment — making the decision the patient would have made based on previously expressed wishes, values, and beliefs — rather than the SDM's own preferences. The principle of double effect provides the ethical justification for administering medications (opioids, sedatives) that relieve suffering but may foreseeably hasten death: the action itself is not intrinsically wrong, the intended effect is symptom relief, the harmful effect is not the means to the good effect, and proportionate reason exists. Medical futility — both quantitative (physiologically unlikely to work) and qualitative (unlikely to achieve meaningful patient benefit) — creates ethical tension when families request interventions the care team considers inappropriate. Structured frameworks such as SPIKES (for breaking bad news) and REMAP (for regoaling conversations) guide clinicians through these difficult discussions while respecting patient and family autonomy.