What approach should doctors take in Advance Care Planning (ACP) dilemmas?

Person-Centered Approach to Advance Care Planning Dilemmas

Healthcare professionals should adopt a person-centered approach when engaging in Advance Care Planning (ACP) conversations, tailoring discussions to the individual's health literacy, communication style, and personal values across physical, psychological, social, and spiritual domains. 1

Key Elements of Effective ACP

• ACP should include exploration of the individual's understanding of ACP and an explanation of its aims, elements, and benefits 1
• The process should explore the individual's health-related experiences, knowledge, concerns, and personal values across multiple domains (physical, psychological, social, spiritual) 1
• ACP should include exploring goals for future care and, where appropriate, information about diagnosis, disease course, prognosis, and treatment options 1
• When appropriate, ACP should include clarification of goals and preferences for future medical treatment and care, including exploration of how realistic these goals are 1
• The process should include discussing the option and role of a personal representative who may act on behalf of the individual when they are unable to express preferences 1

Timing and Implementation

• Initiate ACP during stable phases of disease rather than during acute events to allow for less-pressured patient experience 1
• Individuals can engage in ACP at any stage of life, but content should be more targeted as their health condition worsens or as they age 1
• Values and preferences may change over time, so ACP conversations and documents should be updated regularly, especially when health conditions worsen or personal situations change 1
• Consider introducing ACP during situations when it occurs more naturally (e.g., death of a family member, family planning, prior to cardiac intervention) 1

Overcoming Barriers to ACP

Patient-Level Barriers

• For patients with minimal knowledge about ACP, provide education about its rationale 1
• Address reluctance to begin discussions by normalizing the topic during routine clinic visits 1
• For patients concerned about protecting family members, educate about the advantages of ACP for family members who might face making treatment decisions in the future 1

Healthcare Provider-Level Barriers

• Acknowledge that emotional reactions to disappointing information are understandable and label emotional reactions as they occur 1
• Balance preparation for undesired outcomes with maintaining hope; emphasize these are not mutually exclusive 1
• When facing uncertainty about prognosis, acknowledge challenges with unpredictable disease trajectories and use standardized prognostic indexes to guide predictions 1
• For providers lacking confidence in ACP skills:
  • Practice discussions with colleagues to develop comfort with this language 1
  • Consider standardized approaches to initiate discussions 1
  • Seek continuing education opportunities 1
  • Liaise with palliative care teams to enhance skills 1

Institutional-Level Barriers

• Acknowledge that patients prefer to discuss ACP with clinicians they trust 1
• Develop standardized processes for identifying team members responsible for overseeing ACP dialogue 1
• Address time constraints by advocating for clinical scheduling that allows sufficient time for ACP discussions 1
• Consider scheduling dedicated ACP-specific clinical visits 1

Staged Implementation Approach

• For patients with longer anticipated life expectancy (decades):

  • Invite discussions about future health expectations and preferences 1
  • Explain the rationale and advantages of ACP 1
  • Discuss future health expectations while acknowledging challenges with longer-term prognostication 1
  • Inquire about personal preferences, goals, and values 1

• For patients with shorter anticipated life expectancy or worsening conditions:

  • Provide more targeted information about prognosis and treatment options 1
  • Explore more specific preferences for end-of-life care 1
  • Consider completion of advance directives 1

Communication Techniques

• Healthcare professionals need to display openness to talk about diagnosis, prognosis, death, and dying with individuals and their families 1
• Provide clear and coherent information concerning ACP 1
• Communicate in a respectful and sensitive manner, inquiring about religious, cultural, and background factors that may impact decision-making 1
• Maintain respectful curiosity regarding patients' beliefs and practices 1
• Avoid assumptions based on patients' culture, religion, or background 1

Documentation and Follow-up

• ACP may include completion of an advance care directive 1
• Encourage individuals to provide family and healthcare professionals with copies of advance directives 1
• Advance care directives should have both structured formats for emergency situations and open text formats for describing values and goals 1
• Ensure advance directives are included in hospital files to improve implementation of patient preferences 2