Engaging Patients in Advance Care Planning

ISMS Doctors Making it Work: Julie D. Goldstein, MD, ISMS member since 2002
March 2016

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.