Comprehensive Advance Care Planning


BY: Dr. Barbara Messinger-Rapport

CATEGORY: Medical and Clinical; News and Community
PUBLICATION: Clinical Connections

​Beyond the Living Will Form

Although completion of a living will, and in some states, a POLST (physician order for life-sustaining treatment), are quality markers for hospitals, insurers, and other healthcare organizations, form completion seldom signifies effective communication. Effective advance care planning (ACP) requires the practitioner to understand medical conditions, identify physical, psychosocial and spiritual needs, estimate life expectancy, and elicit values. This process is more likely than a form alone to align medical goals and treatment burden with patient needs.

Treatment burden is a growing problem. Ninety percent of older adults have one chronic medical condition, and three quarters have two or more. Guidelines recommend a multifaceted approach. Diabetics should have blood pressure, cholesterol, and blood sugar controlled. Each such intervention requires one or more different medications. Over 40 percent of patients with diabetes have four or more other conditions. Half of patients with heart failure have five or more conditions. Among the 13 percent of older adults with Alzheimer's disease, 40 percent have five or more conditions. Medication side effects make it nearly impossible to prescribe four or more medications that do not interact with each other or with a dietary constituent.

Prognosis and life expectancy are difficult as well. Luckily, diseases such as HIV and conditions such as metastatic breast cancer are now considered chronic rather than deadly, and metastatic colon cancer can be curable. However, coexistence of multiple chronic conditions alone shortens life expectancy. Superimposing a serious disease, diagnosis, or even a fall on a patient with multiple chronic conditions may limit disease treatability. Additionally, physical, nutritional, and functional deficits alter response to treatment and may lower life expectancy.

Advance care planning is important to all adults. Younger, healthier adults should focus on identifying a proxy to make healthcare decisions for them in case of a serious event such as a fall, motor vehicle accident, etc. The patient should share personal values, including quality of life, longevity and acceptable burdens, with the healthcare proxy.  A brief conversation and advice for a durable power of attorney for healthcare may be the only interventions needed.

Adults with multiple chronic conditions or with one serious condition such as HIV or cancer, and all older adults should consider more comprehensive ACP. Effective planning requires the time, patience and listening skills of the practitioner, usually over multiple visits. Although a change in function resulting from disease progression, hospitalization or trauma provide a natural opening, planning should begin earlier in the course of a patient's illness and be revisited as conditions change.  Patients have fears, goals and priorities. Some may be willing to shoulder physical symptoms and assume substantial burdens including pills, dietary restriction and multiple doctor visits. Others are not willing to sacrifice independence and family time. ACP helps practitioners to individualize a medical plan.

Although patients of geriatricians and palliative care practitioners usually receive substantial ACP, comprehensive ACP needs to be accessible to a wider population. Medical, nursing, and advance practice nurse training programs may benefit from using some of the newer "tools." Directing the right amount of ACP to the right patient at the right times is an art that can be refined with a guided approach and practice.

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