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Back to Module 1: Advance Care Planning Five Steps for Successful Advance Care Planning

Step 1. Introduce the Topic

• Be Straightforward and Routine
• When to Introduce the Topic
• Physician Concerns and Patient Preferences
• Determine Patient Familiarity
• Explain the Process
• Determine Comfort Level
• Determine Proxy

Step 2. Engage in Structured Discussions
Step 3. Document Patient Preferences
Step 4. Review and Update
Step 5. Apply when Need Arises
Complementary Application of the Model for Advance Care Planning

Step 1. Introduce the Topic

Be Straightforward and Routine

When to Introduce the Topic

• Advance care planning is most easily accomplished during stable health

• Health status changes often require a period for adjustment before the patient will have stable goals again

• Patients in need of advance directives can include both:

• Patients with known illnesses, and
• Healthy people who experience an unexpected illness or major trauma

• Whenever possible, routinely initiate the advance care planning process with every adult patient in your practice, regardless of age or current state of health

• An outpatient office or other non-threatening setting is ideal

• In the face of life-threatening illness or other significant change in health status, advance care planning becomes even more necessary

• Try to find a time when there is as much stability and adjustment to the new illness circumstances as possible

• For pediatric patients with a chronic illness, the optimal timing of advance care planning will vary...

• At the time of relapse of disease
• At the time of significant complications
• Before the child is in a state of crisis

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Physician Concerns and Patient Preferences

• Physicians often have a number of concerns that make them reluctant to introduce the topic of advance care planning, including...

• Concern about frightening the patient or sending the "wrong message"


• Uncertainty about the most effective approach to use

• In fact, research shows that...

• Most patients welcome the opportunity to discuss their preferences with their physician


• However, most patients believe that it is the physician’s responsibility to start advance care planning and will wait for the physician’s initiative


• Physicians who routinely engage in the process find it helpful and not too time consuming

• There are legitimate cultural, ethnic, and racial differences in approaches to medical decision making and advance care planning

• However, generalizations should not be used to rationalize the omission of this topic for an individual patient


• Determine early in the therapeutic relationship how a patient wants

• medical information to be shared
• medical decision-making handled

• See Module 2: Communicating Bad News for a discussion of how to do this

• To prevent any misunderstanding...

• Remind the patient that it is the goal of advance care planning to plan for the potential loss of his or her capacity to make decisions, either temporarily or permanently


• Convey the physician’s and health care team’s:

• Commitment to follow the patient’s wishes
• Desire to protect the patient from unwanted treatment or undertreatment
• Desire to help plan for any care taking needs of the patient’s family or significant others

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Determine Patient Familiarity
 

• When introducing the topic, inquire how familiar the patient is with advance care planning

• Some patients may already have advance directives in the form of a living will or durable power-of-attorney for health care

• If this is the case, review the documents and amend them if appropriate


• An advisory medical directive can be used to amend existing statutory documents. (See Step 3)

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Explain the Process
 

• Before beginning the process, be prepared to explain the goals and the process that you recommend using

• You may have literature that you would like the patient to read

• If you are using a validated worksheet, give it to the patient to look over before the next discussion

• Explain the roles of other family members, or a proxy

• If appropriate, introduce other members of the health care team who will be involved in the process

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Determine Comfort Level
 

• While most patients will welcome the opportunity to discuss these matters, be aware of the patient’s comfort level during the introduction of the topic

• If a patient (or parent if the patient is a child) does not seem comfortable talking with you...

• Be supportive and provide information


• But do not force the conversation. It may happen later when the patient is ready

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Determine Proxy
 

• Patients frequently wish to minimize the decision-making burden for family

• Suggest that the patient involve a variety of people to explore how to best manage potential burdens, including...

• Family members
• Friends
• Members of the community

• Ask the patient to identify a possible proxy decision-maker who might act on his or her behalf, to be involved in subsequent conversations

• The best proxy decision-maker is not always a family member or significant other

• Sometimes the decisions are too difficult for people close to the patient who may be overly influenced by their attachment or by burdens of care

• Whether close or not so close, the proxy should be someone whom the patient trusts and who would be willing and able to represent the patient’s wishes

• Encourage the patient to bring that person, or persons, to the next meeting and book a time to follow-up

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