Module 1: Introduction to Advance Care Planning

What is Advance Care Planning?

Advance care planning is a process that helps patients with decision-making capacity guide future health care decisions in the event that they become unable to participate directly in their care. It involves four key steps:

1. Thinking through one's relevant values and preferences
2. Talking about these values and preferences with one's spokesperson, close family members, and health care providers
3. Documenting them with an advance directive
4. Reviewing them periodically and updating as needed

Goals and Expected Outcomes

The goals of advance care planning reflect respect for key ethical principles:

• Autonomy: The patient's right to self-determination in light of personal interests, goals, preferences, and concerns for one's family
• Beneficence: Promoting good
• Non-maleficence: Avoiding harm

In the event of decisional incapacity, advance care planning aims to:

• Minimize the burden of decision making on the spokesperson and/or family members
• Reduce the likelihood of conflicts between the patient's spokesperson, family members, and health care providers
• Minimize the likelihood of over- or under-treatment
• Maximize the likelihood that medical care serves the patient's goals

Benefits for Health Care Providers

As a health care provider engaging patients in advance care planning, you can expect to:

- Better understand the patient's views on:- Who they want you to communicate with for health care decisions when they can no longer participate- Their goals for medical treatment and care in situations where they cannot participate in decisions- Their preferred approach to end-of-life care- Their hopes (e.g., to live longer, have quality relationships) and fears about medical interventions (e.g., permanent cognitive impairment, loss of dignity)- Discuss patient preferences for treatment and care for illnesses with known possible sequelae- Clarify misunderstandings (e.g., success rates of CPR, what mechanical ventilation entails)- Reveal patient preferences that fall outside standard medical practices, providing opportunities to:    - Negotiate culturally sensitive approaches to health care    - Establish limits to patient autonomy based on professional standards- Have better communication with the patient's family members or loved ones due to enhanced shared understanding of the patient's values and wishes- Have fewer conflicts with family members about the approach to end-of-life care

Summary

Understanding the fundamentals of advance care planning demonstrates your commitment to patient-centered care and ethical decision-making. In medical school interviews, you can discuss how advance care planning aligns with your values and goals as a future physician. Engaging in thoughtful advance care planning conversations will prepare you for the challenges and opportunities of your medical career.

Module 2: Initiating Advance Care Planning Discussions

Identifying Patients for Advance Care Planning

While advance care planning is recommended for all adults, certain patient populations are at higher risk for decisional incapacity and should be prioritized:

• Patients with chronic progressive and terminal illnesses
• Those with severe, recurrent psychiatric illnesses
• Patients with debility/frailty (e.g., at risk for delirium with acute illness)
• Individuals engaging in risky behaviors associated with head trauma and coma
• Patients with early dementia
• Those at risk for strokes (e.g., patients with hypertension)

When and Where to Initiate Discussions

Ideally, advance care planning should occur:

• Initially in the outpatient setting
• Upon admission to and discharge from inpatient settings
• Whenever there is a significant change in a patient's social or health status

Strategies for Raising the Topic Sensitively

• Frame advance care planning as a health promotion activity aimed at avoiding harms and promoting benefits.
• Reassure the patient that raising the topic does not imply an unspoken concern.
• Acknowledge that the topic is difficult for many patients.
• Offer resources (e.g., reputable internet-based advance care planning sites) for further reflection.

Recommended Questions and Conversation Aids

Use open-ended questions to explore the patient's values, preferences, and concerns:

1. Should your current preferences be strictly applied or serve as a general guide?
2. Where do you want to receive end-of-life care?
3. Do you have any fears or concerns about the dying process?
4. Are there any life-sustaining treatments you would always want or never want?
5. What should be the goals of care in situations where you cannot communicate your preferences?
6. Are there any circumstances you've heard about where you've thought, "I hope that never happens to me" or "I would never want to live like that"?
7. Who should speak on your behalf if you become too sick to speak for yourself?

Alternatively, suggest that the patient review an existing advance care planning educational resource and use its content to guide the discussion.

Addressing Patient Concerns and Misconceptions

• If a patient lacks a surrogate decision-maker, advise them to write down their wishes in detail and provide copies to their healthcare providers.
• If a patient believes family members will disagree with their wishes, encourage open communication to prevent future disagreements.
• As a trainee, engage patients in advance care planning discussions but seek faculty support when needed, especially for patients with recent terminal diagnoses, severe depression, paranoid ideation, or suicidal thoughts.

Summary

Being able to initiate advance care planning discussions tactfully demonstrates strong communication and empathy skills. In medical school interviews, share examples of how you would approach these conversations, highlighting your ability to build trust and rapport with patients. Engaging in thoughtful advance care planning discussions will prepare you for the challenges and opportunities of your medical career.

Module 3: Advance Directives and Surrogate Decision-Making

Types of Advance Directives

Advance directives fall into two broad categories:

• Instructive Directives: Allow for preferences regarding the provision of particular therapies or classes of therapies.
• Living Wills: The most common example of instructive directives.
• Other Types:
• No transfusion directives
• No CPR directives
• Proxy Directives: Allow for the designation of a spokesperson or surrogate medical decision-maker of the patient's choosing.
• Durable Power of Attorney for Health Care (DPAHC): Empowers the surrogate decision-maker (often referred to as a health care agent) to make health care decisions for the patient in the event of incapacitation.

Importance of Advance Directives in Medical Care

Advance directives are crucial for several reasons:

• Respect for Autonomy: Advance directives allow patients to participate indirectly in their medical care decisions, even if they become decisionally incapacitated.
• Patient-Centered Care: Living wills help ensure that patients receive the treatment they want and prevent unwanted, invasive medical care at the end of life.
• Surrogate Decision-Making: DPAHCs enable patients to choose their surrogate decision-maker, superseding the state's designated order of hierarchy.

Legal Considerations and State-Specific Laws

• Advance directives are recognized in some form by legislative action in all 50 states.
• To be legally binding, directives must be constructed according to the pertinent state legislation.
• In questionable cases, consult the medical center's attorney or ethics advisory committee for guidance.

Interpreting and Applying Advance Directives in Clinical Practice

• Advance directives take effect only when patients are unable to participate directly in medical decision-making.
• Some directives apply only in particular clinical situations (e.g., terminal conditions or incurable illnesses).
• Ambiguous terms in directives must be interpreted by caregivers.
• Informed decisions by patients with decision-making capacity always supersede a written directive.

Handling Disagreements Between Patients, Families, and Healthcare Providers

If there is a disagreement about the interpretation or authority of a patient's living will:

1. The medical team should meet with the family to clarify the issue and explore the family's rationale for disagreeing.
2. If the disagreement is based on new knowledge, substituted judgment, or recognition of misinterpretation by the medical team, the family has more say, and most hospitals would defer to them.
3. If no agreement is reached, consult the hospital's Ethics Committee or Ethics Consultation Service.

Limitations of Living Wills

• Cannot cover all conceivable end-of-life decisions due to variability in clinical decision-making.
• Language employed in advance directives is often imprecise and open to interpretation.
• Patient preferences may change over time or with changing circumstances.

To address these limitations:

• Encourage patients to communicate preferences and values to medical providers and family/surrogate decision-makers.
• Recommend ongoing communication between patients, physicians, and family members.

Summary

Familiarity with advance directives and surrogate decision-making showcases your understanding of the legal and practical aspects of end-of-life care. In medical school interviews, discuss how you would navigate complex situations involving advance directives, demonstrating problem-solving skills and respect for patient autonomy. Understanding the intricacies of advance directives and surrogate decision-making will prepare you for the challenges and opportunities of your medical career.

Module 4: Addressing Challenges in Advance Care Planning

Strategies for Patients Lacking Decision-Making Capacity

When patients lack decision-making capacity, healthcare providers should:

1. Consult the patient's advance directive if available
2. Identify the legally authorized surrogate decision-maker (e.g., healthcare agent, spouse, adult children)
3. Engage in shared decision-making with the surrogate, focusing on the patient's previously expressed wishes, values, and goals of care

If the patient has no advance directive or surrogate:

• Consult hospital policies and state laws regarding decision-making for incapacitated patients
• Involve the hospital ethics committee to guide decision-making based on the patient's best interests

Handling Disagreements Between Patients, Families, and Healthcare Providers

When disagreements arise:

1. Clarify the issues and explore the rationale behind each party's perspective
   • Determine if the disagreement stems from: New information or insights
   • Differing interpretations of the patient's wishes
   • Conflicts of interest
2. Engage in open, respectful dialogue to reach a shared understanding
3. If no agreement is reached, consult the hospital's ethics committee for guidance

Cultural Considerations and Sensitivity in Advance Care Planning

• Recognize that cultural beliefs and values may influence attitudes toward advance care planning and end-of-life care
• Avoid stereotyping and assumptions based on cultural background
• Assess each patient's individual preferences and values
• Provide culturally and linguistically appropriate resources (e.g., translators, educational materials)
• Engage family members and community leaders when appropriate to facilitate culturally sensitive discussions

Limitations of Advance Directives and the Importance of Ongoing Communication

Advance directives have limitations:

• Cannot cover all possible end-of-life scenarios
• May contain ambiguous language open to interpretation
• Patient preferences may change over time or with changing circumstances

To address these limitations:

• Encourage ongoing dialogue between patients, healthcare providers, and family members
• Regularly review and update advance directives to ensure they reflect current preferences
• Promote the designation of a healthcare agent who can interpret the patient's wishes in light of current circumstances

Case Study: Applying Advance Care Planning Principles

Scenario: An 80-year-old woman with advanced dementia is admitted to the hospital with pneumonia. She has no advance directive, and her children disagree about whether to pursue aggressive treatment or focus on comfort care.

Approach:

1. Assess the patient's decision-making capacity and determine if she can participate in discussions
2. Identify the legally authorized surrogate decision-maker(s) (e.g., children)
3. Facilitate a family meeting to discuss the patient's previously expressed wishes, values, and goals of care
4. Provide information about the benefits and burdens of treatment options in the context of advanced dementia
5. Explore the reasons behind the disagreement and work towards a consensus that respects the patient's wishes and best interests
6. Document the decision-making process and the agreed-upon plan of care
7. Provide ongoing support to the patient and family throughout the hospitalization and during care transitions

Summary

Addressing challenges in advance care planning requires sensitivity, effective communication, and a commitment to patient-centered care. In medical school interviews, discuss how you would navigate complex situations involving patients lacking decision-making capacity, cultural differences, and disagreements between stakeholders. Emphasize the importance of ongoing dialogue, regularly reviewing advance directives, and collaborating with the healthcare team to provide care that aligns with patients' wishes and values.

Module 5: Integrating Advance Care Planning into Medical Practice

The Role of Healthcare Providers in Advance Care Planning

As a healthcare provider, you play a crucial role in promoting and facilitating advance care planning:

• Initiate discussions about advance care planning with patients and their families
• Educate patients about the importance and benefits of advance care planning
• Guide patients through the process of clarifying their values, goals, and preferences
• Assist patients in completing advance directives and other relevant documents
• Collaborate with interdisciplinary teams to ensure comprehensive advance care planning

Documenting and Updating Advance Care Plans

Proper documentation and regular updates are essential for effective advance care planning:

1. Record advance care planning discussions in the patient's medical record
2. Ensure that advance directives are easily accessible in the patient's chart
3. Provide copies of advance directives to the patient, family members, and other healthcare providers
4. Review and update advance care plans periodically and when the patient's health status changes
5. Communicate updates to all relevant parties (patient, family, healthcare team)

Collaborating with Interdisciplinary Teams

Advance care planning is a collaborative effort involving various healthcare professionals:

• Physicians: Initiate discussions, provide medical guidance, and document plans
• Nurses: Educate patients, facilitate communication, and advocate for patient preferences
• Social workers: Assess psychosocial needs, provide resources, and support decision-making
• Chaplains: Address spiritual concerns and provide emotional support
• Ethics consultants: Assist with complex decision-making and conflict resolution

Effective collaboration ensures that patients receive comprehensive, patient-centered advance care planning services.

Advance Care Planning Resources and Educational Materials

Provide patients and families with reliable resources to support advance care planning:

• Advance directive forms specific to your state or institution
• Educational brochures explaining the advance care planning process and its benefits
• Websites with reputable information and tools for advance care planning (e.g., National Healthcare Decisions Day, The Conversation Project)
• Support groups for patients and families dealing with serious illness and end-of-life issues
• Referrals to community resources (e.g., legal services, counseling, spiritual support)

Integrating Advance Care Planning into Your Future Practice

As a future physician, consider how you will incorporate advance care planning into your practice:

- **Make advance care planning a routine part of patient care**. Introduce the topic during initial visits and periodic check-ups.- Normalize advance care planning as a standard component of comprehensive care.- **Develop a systematic approach** to advance care planning in your practice setting. Create protocols for initiating and documenting discussions.- Train staff on their roles and responsibilities in the advance care planning process.- **Advocate for policies and systems** that support advance care planning. Participate in quality improvement initiatives related to advance care planning.- Engage in research to identify best practices and improve patient outcomes.- **Continuously educate yourself** about advance care planning. Stay current with legal and ethical guidelines.- Attend conferences and workshops to enhance your skills and knowledge.

By integrating advance care planning into your future practice, you can provide high-quality, patient-centered care that respects patients' values, goals, and preferences.

Summary

Integrating advance care planning into medical practice is essential for providing comprehensive, patient-centered care. As a healthcare provider, you play a key role in initiating discussions, educating patients, and facilitating the advance care planning process. Effective documentation, collaboration with interdisciplinary teams, and the provision of reliable resources are crucial for successful implementation. By incorporating advance care planning into your future practice, you can ensure that patients' wishes are respected and that they receive care aligned with their values and goals.

You're done!