However, there is a notable lack of empirical data about what outcome improvements patients experience, as there are considerable discrepancies in what constitutes as advanced care planning and heterogeneity in the outcomes measured. Advanced care planning remains an underutilized tool for patients. Researchers have published data to support the use of new relationship-based and supported decision making models that can increase the use and maximize the benefit of advanced care planning. End-of-life care conversations
End-of-life care conversations are part of the treatment planning process for terminally ill patients requiring palliative care involving a discussion of a patients prognosis, specification of goals of care, and individualized treatment planning. Current studies suggest that many patients prioritize proper symptom management, avoidance of suffering, and care that aligns with ethical and cultural standards. Specific conversations can include discussions about cardiopulmonary resuscitation (ideally occurring before the active dying phase as to not force the conversation during a medical crisis/emergency), place of death, organ donation, and cultural/religious traditions. As there are many factors involved in the end-of-life care decision-making process, the attitudes and perspectives of patients and families may vary. For example, family members may differ over whether life extension or life quality is the main goal of treatment.
Changes in breathing (indicate neurologic compromise and impending death) and accumulation of upper airway secretions (resulting in crackling and gurgling breath sounds) 
Decreased need for food and fluids, and loss of appetite (caused by the bodys need to conserve energy and its decreasing ability to use food and fluids properly). Decreased oral intake and impaired swallowing (caused by general physical weakness and metabolic disturbances, including but not limited to hypercalcemia) 
Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area). Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake). Skin becoming cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities). Rattling or gurgling sounds while breathing, which may be loud (death rattle); breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs). Turning of the head toward a light source (caused by decreasing vision). Increased difficulty controlling pain (caused by progression of the disease). Involuntary movements (called myoclonus), increased heart rate, hypertension followed by hypotension, and loss of reflexes in the legs and arms are additional signs that the end of life is near.