Engaging Patients in Advance Care Planning
ISMS Doctors Making it Work: Julie D. Goldstein, MD, ISMS member since 2002
Dr. Goldstein is a palliative care physician who provides advance care planning education throughout the Advocate Health Care system. She chairs the POLST (Physician Orders for Life-Sustaining Treatment) Illinois Task Force, and is certified as a Last Steps State Faculty for the Respecting Choices® Last Steps® Advance Care Planning Facilitator Certification program. ISMS recently met with Dr. Goldstein to discuss the advance care planning process. The following is an excerpt; visit www.isms.org/DrGoldstein to read the full conversation.
ISMS: You say that advance care planning involves different priorities depending on a patient’s health status and stage in life. When should the discussions start?
By engaging in ACP conversations early and repeatedly over adulthood, ACP becomes an expected and anticipated "healthy life habit," and is rendered more normal and less anxietyproducing. For a healthy adult, the most important question to ask is “If you should ever find yourself in a situation, even temporarily, where you cannot express your own wishes to your doctors and nurses, WHO in your life would you trust to represent your wishes in making medical decisions for you?” This should be documented using the Power of Attorney for Health Care.
ISMS: After this initial planning, when should a physician initiate the next phase of the conversation?
The next phase of ACP comes when a person has a chronic, progressive condition that is starting to be a factor in daily life. This is the time for detailed conversations with patients about their understanding of their illness, its expected trajectory, and possible future complications and available treatments for those complications. Physicians should help patients explore and articulate their hopes and expectations for the future, which will help provide a context for patients and their loved ones to engage in further discussion of specific wishes for treatments of complications related to their illness.
ISMS: And the last step in the ACP process focuses on end-of-life decisions?
The last phase of ACP focuses on patient preferences with regard to life-sustaining treatments for cardiac arrest and non-arrest emergencies, and wishes for medically administered nutrition, all of which appear on the POLST form. Physicians should ask themselves, "Would I be surprised if this patient died within the next year?" If the answer is "No, I would not be surprised," then this is a patient for whom a POLST discussion and consideration of completing a POLST form would be appropriate.
ISMS: Is it possible to have ACP conversations "too early?"
It is possible to have certain elements of these conversations too far "upstream." For example, most healthy people would want an attempt made to restart their hearts should they suffer cardiac arrest, and so are generally "full code" even without the need to discuss their wishes. Making end-of-life proclamations before there exists a specific medical condition/context within which to make such decisions may be premature, and attitudes often change dramatically once patients are diagnosed and then again when their illnesses progress. This is why it is important to revisit ACP discussions frequently.
ISMS: Medicare has recently started paying for ACP services provided by a physician or other qualified health professional. These conversations seem very involved; are physicians the only ones who can to talk to patients about ACP issues?
If physicians had an appropriately focused, robust ACP conversation with all of their patients, there would be no time remaining to provide the necessary balance of medical care! So, while Medicare reimbursement for ACP is only for physicians and other qualified health professionals, it is best for efficiency to use multiple modalities and an interdisciplinary team to educate patients.
Engaging Patients in Advance Care Planning
According to a 2012 survey cited in the Institute of Medicine’s report Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, more than 75 percent of respondents reported an interest in talking to their physicians about end-of-life care issues. The same survey found that, for more than 90 percent of the respondents, a physician had never raised the subject with them.
Advance care planning (ACP) is a process meant to help patients make decisions about their future health care before they become unable to do so. The two main components of advance care planning are identifying proxy decision-makers and articulating wishes and instructions specific to end-of-life treatment options. The relative time spent on each of these components will change over time, and physicians play an important role in helping patients plan for their future health care needs in ways that are appropriate to their current health care status.
The National Institute on Aging estimates that more than a quarter of older patients who need to make decisions about their medical care near the end of their lives are incapable of doing so. Cognitive impairments, communication difficulties, and limited consciousness are common circumstances that restrict an individual’s ability to evaluate and express his or her preferences related to medical treatment.
Old age or a terminal condition are not the only circumstances that can render a patient incapable of making his or her own decisions. A traumatic accident or unforeseen and incurable injury can affect anyone at any age, and it is critical that patients have planned for and discussed their wishes well in advance of such a catastrophic event.
Illinois law allows for four types of advance care planning documents:
- Power of Attorney for Health Care
- Living Will
- Declarations for Mental Health Treatment
- Practitioner Orders For Life-Sustaining Treatment (POLST) form
Written documentation of a patient’s wishes should always be included in the medical record. Documentation is critical to ensuring proper reimbursement for time spent in advance care planning discussions. More importantly, documentation can help ensure the patient’s wishes are followed should there ever be a time when a patient cannot communicate them on his or her own.
Advance care planning is an ongoing process that evolves over time. The focus should not be on completion of the forms, but on the conversation with the patient, for which the form is written documentation.
Reimbursement for Advance Care Planning
ISMS was actively engaged in the creation of new CPT codes to recognize physician work related to end-of-life care planning discussions with patients. In fact, ISMS is the only state medical society to successfully initiate a new CPT code. Beginning in January 2016, Medicare began paying for CPT codes 99497 and 99498.
By recognizing and reimbursing physicians for advance care planning services, CMS has taken an important step to help encourage physicians to incorporate these discussions into an already busy practice. ISMS and others strongly encourage private insurers to follow CMS' lead in reimbursing physicians for these services.