From the Guidelines
Advanced care directives should be created and regularly updated to ensure that a patient's healthcare preferences are respected, particularly for those with a life expectancy of less than one year, as recommended by the NCCN guidelines 1. To create an effective advance directive, start by selecting a healthcare proxy—someone you trust to make medical decisions on your behalf. This person should understand your values and be willing to advocate for your wishes.
- Next, complete both a living will that specifies your treatment preferences (including resuscitation, ventilation, tube feeding, and comfort care measures) and a healthcare power of attorney that legally designates your proxy.
- Be specific about your preferences for end-of-life care, including pain management approaches and whether you want aggressive interventions or comfort-focused care.
- Once completed, sign your documents with witnesses or a notary according to your state's requirements.
- Share copies with your healthcare proxy, family members, primary care physician, and any specialists you see regularly.
- Store the original in an accessible location and consider registering it with your state's registry if available.
- Review your directive every few years or after major life events to ensure it still reflects your wishes, as suggested by the American College of Physicians 1. These documents are crucial because they reduce family burden during crises, prevent unwanted medical interventions, and ensure your care aligns with your personal values and quality of life priorities. The use of Physician Orders for Life-Sustaining Treatment (POLST) and similar medical order forms can provide explicit direction about resuscitation status and other interventions, and can be particularly useful for patients with advanced chronic illness who have a life expectancy of less than one year, as noted in the study by Bomba and Vermilyea 1. Effective advance care planning based on patient-centered goals of care is critical in achieving quality end-of-life care, and should include discussions about surrogate decision makers, resuscitation, and emergency treatment, as well as specific issues related to the patient's clinical course, such as the management of dementia or the use of implantable cardioverter defibrillators 1.
From the Research
Advanced Care Directive Guidelines
Advanced care directives are an essential aspect of healthcare, ensuring that patients' wishes are respected and their autonomy is maintained. The following points highlight the key aspects of advanced care directive guidelines:
- Advance care planning (ACP) is an ongoing process of communication between patients, family members, caregivers, and healthcare providers to establish values, goals, and preferences for future care 2.
- ACP discussions initiated by advanced practice providers (APPs) can enhance patient-centered end-of-life care, resulting in the completion of advance directive documents and changes in code (resuscitation) status 2.
- Advance directives promote patient autonomy and provide written documentation of a patient's wishes for future care, which is essential for making critical decisions on behalf of the patient when they become incapable 3.
Key Components of Advance Care Planning
The key components of advance care planning include:
- Choosing a surrogate decision maker
- Identifying personal values
- Communicating with surrogates and clinicians
- Documenting wishes in advance directives
- Translating values and preferences for future medical care into medical orders 4.
- ACP often involves multiple brief discussions over time, and opportunities for multidisciplinary teams to incorporate ACP into brief clinic visits are highlighted 4.
Challenges and Limitations
Despite the importance of advanced care directives, several challenges and limitations exist, including:
- Unforeseen limitations and issues that burden the complete and systematic adoption of ACP and advance directives 3.
- The need for education of healthcare providers to increase early ACP discussions with patients and their families 5.
- Resident physicians often do not initiate end-of-life discussions with their patients due to the sensitive nature of the topic and competing clinical priorities 6.
Educational Interventions
Educational interventions can help overcome these challenges, including:
- Formalized curricula, simulations, and academic detailing to increase residents' confidence in leading discussions regarding ACDs 6.
- Educational plans focused on knowledge about advanced directives, communication techniques, and awareness of the patient's level of illness in advanced care planning 5.