Fig. 1From: How to achieve the desired outcomes of advance care planning in nursing homes: a theory of changeTheory of Change map. ACP advance care planning; QI quality improvement; CAP coordinating advisory physician; GP general practitioner. *Since 2000, each nursing home is legally bound to have a coordinating advisory physician (CAP), a general practitioner, preferably trained in gerontology, whose tasks include some of those related to individual end-of-life care situations (consultancy, taking charge of care, or conflict mediation) [81, 82]Back to article page