Page 18 - Delaware Medical Journal - April 2017
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Advance Care Planning in the 21st Century
John Goodill, MD Advance Care Planning (ACP) is a
process of communication between
a patient, family, health care proxy, and health care provider for the purpose of prospectively identifying a surrogate, clarifying treatment preferences, and developing individualized goals across the lifespan.1 It is a process that emphasizes person-centered conversation and decision making that changes over the course and circumstances of a person’s life.
As we approach our annual recognition of the importance of ACP in the form of National Health Care Decisions Day (NHCDD), I care system and society that are impacting our approach to ACP.
More of us are living longer with an increasing burden of illness and frailty. In 2020, there will be 10 million Americans living with four concurrent serious diseases. In 2030, there will be 10 million of us
living beyond the age of 85.1 The Institute of Medicine report in 2014 indicated that
an increasing number of us (up to 70 percent) will lose capacity to make our
own decisions before we die.1 Those of us caring for patients and families at the end of life know how hard the surrogate decision- making role can be, especially when there has been no conversation or decisions made with the patient before the crisis at hand.
Dying in the 21st century is not easy even when one is relatively “prepared.” When
asked, most people would prefer to die at home with peace, dignity, and comfort. Surrounded by their loved ones, they would like to be clear minded enough to make amends, say their goodbyes, and express their love and gratitude.2 Still, most do not want to “go before their time,” and there is much uncertainty about when, exactly,
that is. Modern medicine offers many choices for treatment and extending life as one nears the end. Often these choices preclude the chance for that “good death” most of us wish for. In the end, we can, death for all involved.
Advance Directives (AD) (written directives and power of attorney) are recommended for all adults to identify a surrogate
decision maker and encourage/facilitate a conversation about: What makes my life worth living?; What is most important to me?; and What would I be willing to endure to survive? The likelihood that the ACP is dependent on the quality of the conversation/discussion, who is involved, and documentation.
One of the largest barriers to this process had been public reluctance to engage in any discussion about death and dying. This is changing. The recent books Being Mortal and When Breath Becomes Air, both on the New York Times bestseller list for months, have encouraged thinking and conversation
in the public forum and in health care
3,4
of our lives. With this kind of change in
the public perspective there is increasing demand that our health care system be ready to respond.
ADs have been around for 40 years with little evidence they have been effective at directing medical care. There were many reasons for this and things are changing. In a few instances where health care systems initiated and supported the ACP process, there have been improved outcomes in terms of medical care more aligned with patient/family preferences and reduced costs due mostly to decreased use of non- 5
The quality and frequency of ADs
are improving with improved forms;6 availability in EMRs and registries; improved training of providers; and reimbursement for time spent on the process. Large health care systems are designating resources to ensure a system- wide integration of ADs, all aimed at achieving improved person-centered outcomes.7
It is clear that optimal medical care in the 21st century will need to integrate effective ADs.
I want to conclude with a few comments on a new ACP tool called Delaware Medical Orders for Scope of Treatment (DMOST).
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