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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    Back to Module 1: Advance Care Planning
    Five Steps for Successful Advance Care Planning

    Step 3. Document Patient Preferences Step 4. Review and Update

    Step 3. Document Patient Preferences

    Review the Directives

    • Once the patient has come to some decisions, it is crucial for the physician to
      review the advance directives with the patient and proxy
    • Check for, and help to correct, any inconsistencies and misunderstandings
    • Make sure that the directives provide the type of information needed to make clinical decisions


    Formalize the Directives

    • After a final review is complete, ask the patient to confirm his or her wishes by signing the directives
    • Although any statement of a patient’s wishes, written or verbal, can be considered an advance directive and should be respected by physicians, a formal written document signed by the patient will avoid ambiguity


    Enter Directives Into the Medical Record

    • Once the directives have been reviewed and accepted, the physician must formally document them in the patient’s medical record
    • When a validated worksheet has been used to structure the planning discussion, the completed, finalized, and signed worksheet can itself be used as the entry in the medical record
    • In the absence of a validated worksheet, the physician should describe the patient’s wishes in a written document and ask the patient to review and amend it as appropriate
    • Once everyone is satisfied, have the patient sign the document and enter it into his or her medical record
    • It is also useful for the physician and proxy to sign the advance directive and provide their location information. This action:
      • Offers reassurance to the patient
      • Helps to ensure the physician’s and proxy’s involvement in eventual decision-making


    Recommend Statutory Documents

    • For added protection, patients should be encouraged to complete one or more statutory documents (e.g., living will or durable power-of-attorney for health care) that comply with state statutes
    • Physicians should familiarize themselves with the specific advance directive statutory requirements of their state
    • Resources for obtaining information about state-specific advance directive statutory requirements include:
      • Hospital legal counsel
      • State attorney general’s office
      • Local medical society


    Distribute the Directives

    • It is important to have these records wherever the patient may receive care
    • Place them into a central repository (such as a hospital or a regional or national center)
    • Provide copies to the patient, proxy decision-maker, family members, and all health care providers as appropriate
    • Use wallet cards to help ensure that the information is available when it is needed


    Change the Plan of Care

    • Once preferences have been documented, the physician may need to change the plan of care and put certain things in place to ensure that the patient’s wishes can be followed
    • For patients who may wish to remain at home and never be taken to an emergency room or be hospitalized again, appropriate alternative arrangements may be needed, including:
      • Referral to a home hospice agency
      • Provision of appropriate medications
      • Instructions detailing how to handle symptoms and crises
    • Practical suggestions may be helpful. Consider posting telephone numbers by the home telephone to call in an emergency (e.g., the hospice nurse on call), or numbers not to call (e.g., 911)
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