Promoting Advance Directive Discussions

James S. Powers*

Promoting Advance Directive Discussions.

Advance care planning which includes a discussion of goals of care and preferences about future care improves
patient-centered care at the end-of-life. However, completion of ACP remains
low with an estimated 36.7% of adults having completed an advance
directive in the United States and this number is lower in many other societies worldwide.

Social stigma, personal difficulty accepting the finality of life, and agism all contribute to avoidance of discussions of end-of-life care. The topic of ACP is an intensely personal one, and optimally a longitudinal communication-based conversation between individuals, families, and trusted healthcare professionals.

In the absence of ACP urgent discussions necessitated by medical crises, while necessary, are often
traumatic and may limit involvement of the affected individual and place increased burden on the surrogate decision maker.

Many models to promote ACP are in common use, including education on the importance of advance directives for primary care providers, clinical prompting at the point of patient care, embedding palliative care trained clinicians in chronic disease and oncology clinics, and inquiring about the presence of advance directives on presentation at healthcare facilities.

More recent models include targeted outreach by providers utilizing a risk stratification tool to identify high-risk patients for ACP completion, outreach by non-provider healthcare workers, and evaluating the effectiveness
of billable ACP discussions to enhance form-based ACP documentation in the healthcare record.

It is time to reimagine the approach to ACP and create a cultural shift in society
to enhance the discourse on end-of-life care, taking a public health approach. One model may be to integrate consideration of ACP into regular benefits “check-ups” among employed individuals during enrollment and open season periods.

Palliat Med Hosp Care Open J. 2020; 6(2): e3. doi: 10.17140/PMHCOJ-6-e010