Start Talking to Patients about Advance Care Planning Today!

Advance care planning (ACP) is not only for older adults or terminally ill patients; all patients benefit from these discussions with their doctor to avoid making important decisions in the middle of a health crisis. Navigating these discussions is inherently difficult from both a provider and a patient/family perspective as they tend to be emotionally charged and are heavily affected or shaped by personal, familial, cultural, and socioeconomic considerations.

There are several types of ACP, many of which are subject to differing states laws. Examples include:

A living will is a legal document that instructs physicians on when to use, withhold, or withdraw life-sustaining treatment if the patient is deemed incompetent, has an end-stage medical condition, or is permanently incapacitated and unable to make emergency medical decisions.

Durable power of attorney for healthcare designates an adult proxy, agent, or surrogate to make medical decisions on a patient' s behalf if the patient loses decisional capacity.

Physician Orders for Life-Sustaining Treatment (POLST) is a state-approved document that is both a holistic method of planning for end-of-life care and a specific set of medical orders that ensure a patient' s wishes are honored.

A do-not-resuscitate (DNR) order is a type of advance directive that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) on an individual known to suffer from an irreversible medical condition who experiences cardiopulmonary or respiratory arrest, and who has requested that CPR be withheld in those circumstances. DNR orders must be signed by a medical provider. Other instructions frequently contained within the DNR include do-not-intubate and do-not-hospitalize orders.

There are several best practices that all practitioners can follow to ensure patient wishes are followed, especially during serious health crises, including:

• Begin ACP conversations with young adult patients and include them as part of routine care; do not wait until patients are geriatric or terminally ill.
• Understand that ACP conversations are part of an ongoing process rather than a one-time event.
• Check in periodically with patients to ask about their wishes.
• Be direct, honest, and sensitive, and explain why planning is important at any age.
• Provide input on treatment possibilities, recovery, and possible outcomes (e.g., CPR) to help patients consider their options.
• Offer state-approved ACP forms (e.g., advance directives or POLST).
• Discuss the importance of identifying a surrogate decision-maker.
• Use palliative care teams to help facilitate conversations and care.
• Integrate a routine set of questions into a formal assessment system.
• Acquire background knowledge regarding local racial/ethnic/cultural communities and their beliefs and values surrounding end-of-life care.
• Document discussions with patients and any resources provided in the medical record.
• Ensure the completed advance directive is copied into the patient medical record; provide copies to the patient and their surrogate(s).
• Create opportunities for training and discussion with colleagues, such as ACP debriefs and workshops.
• Create opportunities for community groups to facilitate conversations regarding end-of-life issues among the populations they serve.

ACP may be difficult, but with the proper tools and expectations, healthcare providers can successfully navigate this issue.

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