Advance Care Planning

Why Care About Advance Care Planning (ACP)?

ACP is a process by which patients communicate their goals of care, which can entail the assignment of healthcare proxies (HCPs), preferencing end-of-life treatments (e.g. CPR and/or intubation) and their location (e.g. home versus hospital), and completing advance directives (ADs), among other actions. ACP emphasizes patient autonomy, and is associated with end-of-life care that is better aligned with patient preference and improved patient and family satisfaction. However, ACP is underutilized; a 2017 report found that while a little over half of Americans had had conversations on end-of-life care with a loved one, <20% had done so with providers, and only about a quarter had documented their wishes.

Those who wish to learn more about terms pertaining to ACP can find a glossary here.

Why is ACP particularly relevant now?

• COVID-19 can have an unpredictable and precipitous clinical course. Initially stable patients can rapidly progress to respiratory failure. Such situations severely limit the ability for patients to express treatment preferences, which is further compounded by restrictions on visitation by loved ones.

• COVID-19 imposes a disproportionate burden on the elderly and those with serious comorbidities. ACP is especially crucial for these vulnerable patients, and as with ACP in any context, should begin prior to acute illness when discussions and decisions can take place in a calm, supportive, and unhurried atmosphere.

• COVID-19’s infectious nature and strain on PPE mean that resuscitation (e.g. CPR and defibrillation) of affected patients exposes healthcare workers to greater risk. By engaging in ACP with patients about resuscitation, healthcare workers can ensure care that aligns with patient preferences, and may also avoid unnecessarily risky care that is undesired.

  • These issues have sparked discussions in hospitals on potentially limiting or foregoing resuscitation in patients with COVID-19. How patient preferences should intersect with these potential policies is beyond this module's scope, but you can read more about this here.

Frameworks for ACP

These are difficult conversations. Thus, it can be helpful to have a framework for approaching this topic. While various frameworks exist (such as the previously described REMAP mnemonic for goals of care), they share many common characteristics. Here, we will focus on Ariadne Labs’s COVID-19 conversation guide for outpatient care, for which there is also a video demonstration.

Process

1. Set up the conversation: ascertain whom to speak to (e.g. patient and/or family), acknowledge uncertain times, and normalize topics being discussed.

2. Assess patient understanding: gather information on patient’s awareness of their condition and how coronavirus could affect their health.

3. Share information: explain patient’s likely prognosis if they were to become sick and require more intensive treatment.

4. Explore priorities: ask patient about hopes and worries, their thoughts on different medical treatments they may want, and whether they have discussed such topics with their loved ones.

5. Review conversation: reflect on what the patient has discussed, provide recommendations on completing a health care proxy, advanced directive, and/or Physicians Orders for Life-Sustaining Treatment (POLST) as appropriate, and provide reassurance.

   1. ACP is a process. Multiple conversations focusing on different aspects may be ideal, especially in the outpatient setting.

This is not a one-size-fits-all approach, but it contains themes that are useful for medical students even if they may not typically lead such conversations. For example, during an admission interview, a student could segue into components of ACP by asking a patient if they have a health care proxy. Regardless of the answer, the student can then explore patient hopes and worries (e.g. “have you spoken to your proxy about your priorities?” or “if your health worsens, have you ever thought about what your priorities would be for treatment?”), as well as thoughts on desired treatments in relation to code status.

Thought questions:

• Imagine that you are Diane’s new PCP who has seen her once before. You are about to conduct a telehealth follow-up for her comorbidities (i.e. COPD, heart failure, depression, and anxiety). How might you broach ACP, and what wording might you use? How would you explain the differences between advance directives and POLSTs if she asks if she needs them?