By Ryan Van Wert, MD
Advance care planning (ACP) is a thoughtful way for individuals to document their wishes for end-of-life care. It’s a proactive step that helps people tell loved ones and healthcare providers how they wish to be treated. The consequences of poor ACP are dire. Vulnerable individuals who are unable to speak for themselves may receive unwanted interventions against their wishes. Families are forced to make decisions about a loved one’s care with no knowledge about his or her preferences. As an intensive care physician, I have seen this scenario play out too many times.
Baby Boomers are aging, and the implications for health care will be significant. By 2030, everyone who falls in this demographic – born between 1946 and 1964 – will be 65 years of age or older. The “Aging in the United States” report predicts that by 2060, one-quarter of all Americans will fall into this post-retirement age group.
At the same time, healthcare reimbursement models are evolving as we shift from fee-for-service to value-based care. To receive compensation, the new agreements require providers to show evidence of outcomes and cost reductions. That’s where ACP programs can play an important role by improving care at the end of life by limiting unwanted treatments, hospitalizations and reducing expenditures.
Succeeding with ACP Programs
Healthcare organizations, physicians, health plans, patients and their families have important roles to make sure ACP is conducted appropriately and documents are available when and where needed.
To be successful, it’s important to consider these four key components when embracing ACP programs:
Most medical schools do not yet provide training on how to have conversations about end-of-life care. This creates an opportunity for healthcare organizations to realize the benefits of ACP by educating care providers about how to have difficult conversations, what situations should trigger proactive discussions, and what types of ACP documentation is needed.
There are signs of progress. Four medical schools in Massachusetts have a joint agreement to teach students how to talk to patients about their overall life goals, which in turn can inform end-of-life treatment decisions. Medical students at the Oregon Health & Science University now receive training on how to deliver difficult health news and talk to patients about dying.
All ACP starts with a conversation. At the beginning of 2016, Medicare issued two codes (CPT 99497, 99498) to encourage ACP discussions and provide a way for providers to be reimbursed when engaging in these important dialogues.
ACP conversations should happen with patients at various points throughout their lives. The concept of ACP should be introduced to adults during well-care visits, so they understand their options and how to implement plans for themselves or family members should they be unable to speak for themselves. Based on this conversation, a value-based summary or advance directive should be completed. And, with over 30 million adults serving as caregivers for older adults, it’s a good way to spark inter-generational dialogue for those making decisions about their parents’ or other loved ones’ health care.
The diagnosis of chronic conditions or serious, life-limiting illnesses should trigger more involved conversations, resulting in the completion of a medical note, such as a Life Sustaining Treatment form. Recognized in most states, the National POLST Paradigm is a standardized ACP tool that enables individuals with serious illnesses or frailty to spell out their wishes and help prevent extraordinary unwanted treatments.
Conversation is just the first step. The plans created based on these discussions need to be made available at the point of care. Physical documents stored in a safe deposit box are not useful in the critical moments of an emergency situation. What’s more, there’s research to support that EHR systems are not optimized to share accurate care plans in the time of an emergency. The best option is to provide access to a single source of documentation about care preferences across the care continuum.
- Capture: ACP documents should be captured electronically by individuals, their families, and their providers. With proper technology, we can ensure that conflicting choices are not selected and that all required signatures are captured.
- Access: All care providers need to be able to easily and quickly access these documents at every point of care. This should include being able to easily identify the most recent, valid ACP document, and access to all previous documents.
- Honor: Quick, easy access to the most recent ACP document ensures that care providers can act quickly, and honor wishes for end-of-life care with confidence.
Healthcare organizations and providers benefit from building an evaluation component into ACP programs to better understand the impact and make changes as needed. It’s a valuable step to quantify the results of formalized ACP program to:
- Reduce ICU utilization
- Reduce unnecessary hospitalizations
- Increase patient and family satisfaction
- Achieve quality and value metrics
The Time is Right to Embrace ACP
Ultimately, the purpose of ACP is to start the conversation early, honor end-of-life wishes and improve the quality of care at a very difficult time for individuals and their loved ones. Changing reimbursement models support the value of ACP to control what treatments are desired and reduce unwanted care. By incorporating these four key components into ACP programs, providers can meet the needs of patients and achieve better clinical and financial outcomes.
Ryan Van Wert, MD is the co-founder and Chief Executive Officer of Vynca, part-time Clinical Assistant Professor at Stanford University, and the Assistant Director of the Faculty Fellows Program at the Stanford Byers Center for Biodesign.