With an aging population, the government is allocating more resources in the care of the elderly. Hospitalization may not be a natural desire of the sick nursing-home resident. Advance care planning is explored as a strategy to promote the right site of care, defined here as the most appropriate place that patients can receive treatment by medically competent teams at the lowest possible cost (Khaw, 2007). Advance care planning, when practiced with residents in nursing homes, comes with unique challenges, which this paper will illustrate. This paper also presents the multiple roles of a social worker in advance care planning and concludes with factors that contributed to effective advance care planning facilitation.

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