 Intervention Patients in the intervention group will be offered a formal ACP discussion with the researcher. This will be conducted as a discussion between the researcher and the patient based on the Respecting Patient Choices model.11 This programme, developed at the Austin Hospital in Melbourne, Australia, is based on the Respecting Choices programme and involves a coordinated approach to ACP whereby facilitators, in collaboration with the treating doctor, assist patients and their families to reflect on the patients goals, values, and beliefs, and to discuss and document their future choices about health care. Patients are encouraged to appoint a proxy and to document their preferences about end-of-life care; including the preferences for life prolonging treatments and cardiopulmonary resuscitation recorded on an Advance Care Plan see Appendix 2. Whenever possible, treating doctors will participate in the discussion to ensure that the patients understand their illness, treatment options, and likely prognosis. The discussion will be audio taped for scientific use and the ACP will be documented in EPJ. The discussion will take place at the hospital or at the patients home. With the acceptance of the patient, the general practitioner and the community nurse will receive a copy of the ACP documents. Patients will be encouraged to include their closest relative in the ACP discussion. The aim is to complete the ACP discussion within two weeks after the identification of patients in the outpatients clinic. Consistent with usual practice patients in the control group will receive usual medical and psychosocial care but not a formalised ACP discussion. 