Advanced Care Planning for the Severely Ill Home-dwelling Elderly

Inclusion and exclusion criteria for patients and relatives the quantitative and triadic sub-study: Inclusion criteria for patients: * Home-dwelling * 70 years or older * Acutely admitted to the participating unit * Sufficient language proficiency in Norwegian to answer the questionnaire * Clinical frailty score of 4 or more * The physician responsible for the patient's medical care answers "no" to "Surprise question" from Gold Standards Framework proactive identification guidance * Both patient and a close relative (preferably the closest relative) would participate in ACP together if offered * Both patient and the close relative consent to participate in the research project Exclusion criteria for patients: * The patient is not competent to consent to research participation * The patient is expected to die within 24 hours * The patient has participated in ACP prior to the current hospital admission * In the intervention arm * ACP is not conducted with patient, next of kin and physician before hospital discharge * The clinician that participated in the ACP conversation has not consented to research participation * In the control arm * The patient would not have been able to participate in ACP during hospitalization * An attending clinician has not consented to research participation Inclusion criteria for relatives: * A close relative of a patient who fulfill all inclusion criteria and no exclusion criteria; and who would be willing to participate in ACP together with the patient if offered * 18 years or older * Sufficient language proficiency in Norwegian to answer the questionnaire * Both patient and the close relative consent to participate in the research project Exclusion criteria for relatives: * The relative is not competent to consent to research participation * In the intervention arm * ACP is not carried out with the patient, next of kin and attending clinician before hospital discharge * In the control arm * The relative would not have been able to participate in ACP during hospitalization