Planning For A Good Death
12/1/2010
What Is Advance Care Planning?
The definition of advance care planning is a “structured dialogue (communication and negotiation) with the goal of shaping clinical care by the patient’s preferences and goals in life over time,” says says Judith Peres, a clinical social worker and independent consultant in hospice, nursing facility, and palliative end-of-life care policy.
These are targeted by age, medical condition, and prognosis and tailored to health status, circumstances, and beliefs and values. They must also be flexible and continuous. She says the planning is an iterative process, one that evolves over time. It allows people to define the type of end-of-life care they want and explains the extent in which a person wants life-sustaining medical treatments and preserves personal autonomy. The process also identifies a surrogate decision maker.
Why Wouldn’t Directives Be Followed?
Some of the reasons advance directives are not followed is that most people never fill one out. Other reasons are that the ones that are signed may not reflect the changing preferences and circumstances of the patient. Peres notes that research also shows sometimes a health care provider has no idea the patient has an advance directive or if they do know about it, the documentation may not be present in the medical record when it is needed.
Finally, there can be unresolved physician/family conflicts that remain at the bedside.
Best practices in this specific, and particularly important part of end-of-life care, show that a “systems” approach works best. Other paths for success should have providers embed advance care planning in the larger routine of the facility; create ongoing monitoring mechanisms to reinforce changes or improvements, like feedback loops, accountability systems, fall-back systems, and quality improvement efforts; sustain a program over the long haul through ongoing education and accountability; a multi-disciplinary approach; and detailed job descriptions and training.
Interventions that involve a range of professionals and other stakeholders in advance care planning have been successful in increasing the number of advance directives in accordance with patients’ wishes. The focus of advance care planning must shift from a focus on formal written advance directive forms to a developmental discussion process, Peres notes.