Advance Care Planning for Healthcare Professionals

ENSURING PATIENT HEALTHCARE WISHES ARE HONORED
Advance care planning is most effective when it is part of a coordinated effort that can be used across healthcare settings by paramedics, in hospitals, and in residential care facilities.

  • WHAT IS ADVANCE CARE PLANNING?

    The goal of advance care planning (ACP) is to help ensure that patients receive medical care that is consistent with their values, goals, and preferences. Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their informed decisions regarding future medical care. The nature of ACP may vary depending on whether the person is healthy, has mild to moderate chronic illness, or has an advanced life-threatening condition and is thought likely to die within the next one to two years. Regardless of the clinical scenario, advance care planning should be proactive, appropriately timed, and integrated into routine medical care.

    Advance Care Planning is an important part of routine, high-quality healthcare for all adults at all stages of life and health. When integrated in the outpatient or community setting and early during the course of healthcare, advance care planning discussions help normalize the concept of planning, and orient individuals to the importance of regular review and update of written plans. ACP improves communication between patient, loved ones, and clinicians resulting in shared decision-making.

    Resources:

    Advance Care Planning Decisions
    Conversation Ready White Paper
    Conversation Ready Toolkit for Clinicians

  • MEDICARE REIMBURSEMENT

    Advance Care Planning conversations and completion of advance directives are reimbursable by Medicare.

    Resources:

    Centers for Medicare and Medicaid Services (CMS) – Advance Care Planning Fact Sheet
    End of Life Care Conversations: Medicare Reimbursement FAQs – Conversation Ready

  • BENEFITS OF ADVANCE CARE PLANNING (ACP)

    Patients, family members, staff, and medical providers all benefit from advance care planning. It reduces family and healthcare provider stress and anxiety, and it increases patient and family satisfaction with care. In prospective studies and randomized trials, advance care planning has significantly improved multiple outcomes, particularly for patients with serious illness. These include:

    • ACP honors a patient’s right to self-determination and helps ensure that patients receive care that is consistent with their preferences and the requirements of the Patient Self-Determination Act of 1990.
    • ACP is associated with higher patient satisfaction with the quality of healthcare.
    • ACP improves communication between patient, loved ones, and clinicians resulting in shared decision-making.
    • ACP reduces moral distress among health care providers.
    • ACP increases likelihood that clinicians and families understand and comply with a patient’s wishes.
    • ACP lowers risk of stress, anxiety, and depression in surviving relatives of deceased persons.
    • ACP provides guidance to family members and reduces their decisional burden about whether they are following their loved ones’ preferences. Family members feel better prepared to make decisions for their loved one. Family is better prepared about what to expect during the dying process.
    • ACP helps healthcare surrogates by providing a framework that they may utilize to inform decision-making, keeping in mind the patient’s goals, values, and beliefs, as well as their treatment preferences.
    • ACP is associated with higher rates of completion of advance directives, a reduction in hospitalizations at the end of life, fewer invasive treatments at the end of life, and increased utilization of hospice and palliative care services.
    • ACP increases the likelihood that a patient will die in his/her preferred environment.
    • Emerging data indicates advance care planning reduces cost of end of life care, without increasing mortality.

    Source:

    Advance Care Planning and Advance Directives. Karen Detering, MD, Maria J. Silveira, MD, MA, MPH. In UpToDate

  • STAGES OF ADVANCE CARE PLANNING (ACP)

    The nature of ACP may vary depending on whether the person is healthy, has mild to moderate chronic illness, or has an advanced life-threatening condition and is thought likely to die within the next one to two years. In an ideal ACP discussion, clinicians, the patient, and his or her loved ones think through particular approaches to follow if (or when) the patient’s health declines. These discussions will then drive specific medical treatment decisions that can be expressed and recorded in several types of legal documents called advance directives. Advance Care Planning can be viewed as occurring over a person’s lifetime in different stages.


    STAGE ONE: No serious illness

    Target Population: All adults who have not yet made plans.
    Tasks for the patient to complete at this stage:

    1. Identify a Healthcare Representative – Everyone aged 18 and older should choose someone to speak on their behalf if they become    unable to speak for themselves.
    2. Learn about different life sustaining procedures and what they can and cannot do.
    3. Complete a Living Will Declaration OR Life Prolonging Procedures Declaration.
    These documents provide guidance for the kind of care the patient wishes to receive.
    4. Discuss plans for future review and conversations.


    STAGE TWO: Serious Illness

    Target Population: Individuals with serious illness. These persons may have complications from advancing illness, co-morbidities, frequent clinical encounters, and/or functional decline.
    Goal: Identify treatment preferences if illness complications or treatments would result in unacceptable outcomes and a poor quality of life as defined by the person. Communicate preferences with healthcare representative, loved ones, and healthcare providers.

    Tasks for the patient to complete at this stage:

    1. Obtain disease specific information. With assistance from the physician, the patient should obtain an understanding of the possible course of illness and various treatment options. The patient should be assisted to clarify clinical outcomes that are acceptable or not acceptable. Examples of unacceptable outcomes of illness complications or treatment might be: less than 5% chance of living; can’t walk or talk; not knowing who you are or whom you are with; treatment that causes nausea.
    2. Review and update advance directives with healthcare representative, physicians, and loved ones.
    3. Discuss plans for future review and conversations.


    STAGE THREE: Advanced Serious Illness

    Target Population: Adults with serious injury or illness or advanced frailty, whose healthcare professionals would not be surprised if they died in the next one to two years.
    Goal: Identify treatment preferences if illness complications or treatments result in unacceptable outcomes and a poor quality of life as defined by the person. Communicate preferences with healthcare representative, loved ones, and healthcare providers.

    Tasks for the patient to complete at this stage:

    1. Obtain disease specific information. Patient assisted to explore understanding of illness, symptoms, complications, hopes, and goals for living well.
    2. Learn about life sustaining procedures and what they can and cannot do.
    3. Learn about and consider completing physician orders for treatment.
        • Out of Hospital Do Not Resuscitate Order
        • Physician’s Orders for Scope of Treatment (POST)
    4. Review and update advance directives with healthcare representative, physicians, and loved ones.

    Resources:

    Having the Conversation at three life stages: A Guide for Practitioners

  • THE ADVANCE CARE PLANNING FACILITATOR – AN EMERGING ROLE IN HEALTHCARE

    The advance care planning (ACP) facilitator is an emerging role in routine, high-quality healthcare. ACP facilitators are instrumental in helping individuals, their families, and their loved ones become more engaged in person-centered decision making. The role of the ACP facilitator is a critical component of any program seeking to achieve the goal of advance care planning —to know and honor an individual’s informed healthcare decisions.

    Because advance care planning is not a one-size-fits-all conversation, ACP facilitators benefit from training to have conversations with individuals at different stages of health and in different settings of care.

    Resources:

    Helping Individuals Make Informed Healthcare Decisions: The Role of the ACP Facilitator

  • LOCAL ADVANCE CARE PLANNING FACILITATORS

    Putnam County Hospice and Palliative Care Association provides training and support for local advance care planning (ACP) facilitators.  Contact the Association at This email address is being protected from spambots. You need JavaScript enabled to view it.  to inquire about training opportunities.  

    To connect with a local ACP facilitator, please click here.