Why? - Why should advance care planning be a part of routine care?

Advance care planning should be part of routine health care for many reasons. Patients have a right to take an active role in their own health care. Unfortunately, there are times, such as sudden illness or an accident, when direct participation by the patient is not possible. Advance care planning affords the patient the opportunity to exercise his right to influence the health care provided through an advance directive document and through an informed proxy decision-maker.

Advance care planning is of value to the physician in the care of individuals who have a protracted terminal condition. A discussion of health care values and beliefs prior to the onset of late stage terminal care promotes preparation by the patient and family and reduces barriers to an open discussion of the patient's wishes.

Advance care planning at any stage in a patient / physician relationship can engender a sense of mutual respect that strengthens that relationship. If a patient becomes incapacitated, family members are likely to be more satisfied with care if they have been involved in the process to create a common expectation and understanding of the patient's healthcare wishes.

Who? - What Patients Need Advance Care Planning

Advance care planning will benefit the physician's care of all patients. It is advisable for the physician to make advance care planning a part of routine care for all patients: young and old, healthy and ill.

A large majority of patients and close family members state that they are interested in discussing end-of-life issues with their physician. Most expect their physician to initiate such dialogue. By initiating such a discussion, the physician creates an atmosphere in which the subject is acceptable. Before conducting advance care planning with patients, it may be helpful for physicians to complete their own advance directives. Beyond being an excellent teaching mechanism, it also enables the physician to assure a worried patient that advance care planning is a routine matter for all individuals.

Click here to download Advance Directive documents and instructions

In the case of pediatric patients, advance care planning may be best initiated when a terminal condition is diagnosed or a sudden illness or accident takes place. Parents or guardians are intricately involved in health care decisions for their children, and it is advisable to include the child in the conversation whenever possible.

How? - How to get started and what to get done.

Introducing the topic of advance care planning to patients is the hardest part of the process. Physicians fear that if they initiate the discussion, patients will feel alienated, become fearful, or be reluctant to discuss the issue. Research, however, demonstrates that the vast majority of patients welcome the opportunity to discuss their advance care wishes with their physician.

Tips for opening the conversation:
• Present the subject in a straightforward manner using clear language.
• Explain that advance care planning is part of your routine with all your patients, regardless of health status.
• Assure the patient that there is nothing about his/her health status that he does not already know.
• Suggest the patient select a family member or friend to participate in the conversation.

"First, I want to assure you that I am not raising this subject because of any new concerns I have about your health. As I have previously said, your condition is stable, and I have every expectation that you will remain so in the near future. However, I believe it's best if we begin these discussions when you are stable, so we don't have to raise these issues for the first time in an emergency situation."

Using an Advance Directive document will add some structure to the conversation. Click here to download Advance Directive documents and instructions.

Identifying a surrogate decision-maker is of key importance. The patient may want to invite this person to participate in future conversations that involve health care planning.

"If you ever became so ill that you were unable to speak for yourself, who would you want to make decisions regarding your medical care?"

Click here to download a Health Care (Medical) Power of Attorney form and instructions.

Your patient cannot give you an answer now to every possible medical treatment decision that may arise, but you can elicit an understanding of the patient's values and preferences toward health care that will offer both you and the surrogate decision-maker guidance:

• Who would you like to make decisions for you if you are unable to do to so in the future?
• What is the goal of your care - what is "quality of life" to you?
• What treatments (if any) would you never want?

When? - How to fit Advance Care Planning into a busy day

It is hard to imagine having the time to engage each patient in an advance care planning conversation and keep pace with an already busy schedule. This concern may certainly be justified, but there are steps the physician can take to address this concern:

• Provide educational material to patients about advance care planning.

  Patients and families can begin their exploration of values and preferences independently. The physician can clarify questions about medical care, treatment options and prognosis. This collaborative model encourages the patient to take personal responsibility for future health care decisions.

  Click here to order educational packets for your patients.

• Train other health care providers in the practice of advance care.

  Effective advance care planning is never a single conversation with a patient or family. It is an ongoing discussion of values applied to a current clinical situation - across a continuum of time, providers, and sites of care.

  Click here to request training materials or to schedule a training seminar in Advance Care Planning.

• Review advance care planning with patients regularly.

  Touch base with the patient and family routinely. In this way, conversations and decisions are ongoing and not as momentous for either the physician or the patient.

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