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Best Practices for Advanced Care Planning, End-of-Life Care

Effective advanced care planning discussions center on strong interpersonal skills and provider empathy.

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Source: Thinkstock

By Sara Heath

Clinicians looking to improve their advanced care planning conversations and end-of-life care for their patients should utilize strong interpersonal skills and supplementing them with health IT use.

Advanced care planning is the process by which patients, providers, family members, and other stakeholders identify patient preferences for end-of-life care in the event that the patient is no longer able to communicate their wishes.

According to the National Hospice and Palliative Care Association, advanced care planning decisions include, but are not limited to, the following:

  • Discussing information on the types of life-sustaining treatments that are available.
  • Deciding what types of treatment a patient would or would not want should he or she be diagnosed with a life-limiting illness.
  • Sharing personal values with loved ones.
  • Completing advanced directives to put into writing what types of treatment the patient would or would not want should he or she be unable to speak for themselves.

Advanced care planning discussions are an important part of  ensuring both patient satisfaction and a patient’s dignity. When a provider can identify a patient’s preferences at the end of their life, they can ensure their care will be respectful, regardless of the patient’s ability to communicate their wishes.

A 2016 survey of healthcare providers showed that 99 percent of clinicians found advanced care planning discussions helpful and important. One year ago, Medicare began offering reimbursement for providers who engaged in these conversations.

But despite recognized importance and reimbursement opportunities, that same survey showed that only 14 percent of providers actually billed Medicare for advanced care planning conversations.

Just under half of respondents said they did not conduct these discussions because they were uncomfortable doing so, with 29 percent saying they receive inadequate support and training in advanced care planning.

With providers facing both an increasing emphasis on patient satisfaction and reimbursement opportunities for identifying end-of-life care needs, it will be important for them to develop the skills necessary to conduct advanced care planning conversations. These skills should foremost be interpersonal, but as the healthcare industry continues to embrace technology, providers may also turn to digital tools to help support their efforts.

Use strong relationships, empathy, to drive discussion

According to an advanced care planning guide developed by Dr. Richard Balaban, these conversations should center on several sensitive touchpoints for patients nearing the end of their lives.

Discussions should address the broad array of concerns shared by most dying patients and families: fears about dying, understanding prognosis, achieving important end-of-life goals, and attending to physical needs,” says the guide, which was  published by the National Center for Biotechnology Information.

When approaching such emotional and difficult topics, providers must foremost utilize their interpersonal skills. Exercising empathy and drawing on a strong patient-provider relationship will help the provider be more comfortable with the patient, and vice versa.

Patients and families speak more openly and are more trusting when they feel their doctor's empathy and compassion. A caring connection can be enhanced by recognizing the stresses that illness imposes on a patient and family,” Balaban wrote. “By encouraging a patient to speak openly, the subject of death can become less of a taboo.”

Providers can try using empathetic language and frequently revisiting patient care goals to ensure clear communication during advanced care planning conversations. Additionally, providers must be understanding of cultural differences amongst patients and how they may influence certain end-of-life preferences.

Balaban also noted that advanced care planning should be an ongoing discussion in order to ensure patients carefully consider their preferences and clearly articulate them.

“Although general thoughts can be explored in initial discussions, several factors mediate against making detailed end-of-life decisions significantly in advance of one's death. First, patients' preferences may not be durable over time,” Balaban said.

“Second, early discussions, by definition, must focus on the hypothetical as it is impossible to anticipate all relevant medical decisions of a particular case. Hypothetical discussions, however, are hampered by real limitations in communication.”

Providers should re-engage in these discussions when new developments occur as the patient approaches the end of his or her life. When reopening the conversation, providers should continue to leverage strong communication skills and warm relationships with patients and their caregivers.

Providers can somewhat lean on digital health

Digital health tools have patient education benefits, acting as an information repository for certain treatments patients might face at the end of their lives. When patients have access to that information, they can decide whether those treatments are right for them and their end-of-life needs.

“Towards the end of life, many patients get care that they wouldn’t want if they really understood what it entails,” said Steve Wardle, CEO and co-founder of Iris Plans, a patient education tool geared toward advanced care planning. “This puts patients in the driver’s seat and empowers them to be more active in their decision-making.”

Telehealth technology is also beneficial. Telehealth allows patients and providers to add important stakeholders such as specialists, legal teams, and family members onto a call to discuss preferences for end-of-life care.

“Telehealth has an advantage over a health clinic: Families who are spread across the country can join in the call,” Wardle said. “It’s important to have the next of kin who will be walking through the illness with you.”

EHR notes are critical for delivering on patient preferences

While it is important to engage in an empathetic and informative advanced care planning conversation, that is only half of the battle. Providers must also ensure they carry out these preferences during actual end-of-life treatment.

According to a 2016 study, it is vital for advanced care planning decisions to be posted in the EHR. This ensures all providers can access patient preferences and adhere to them while delivering treatment.

Advanced care planning activities must be documented in the medical record and readily retrievable in any setting in which patients receive care,” the researchers said. “Signed documents such as advanced directives and standardized, state-approved physician or medical orders for life-sustaining treatments provide a legal foundation for tailoring treatments to patient preferences.”

However, providers only document advanced care planning preferences in the EHR 30 percent of the time, the researchers said. In order to improve this figure, the researchers asserted that EHR developers must include advanced care planning tabs in their technologies, and providers must take note of these.

The study introduced these tabs to providers between 2012 and 2013, and saw a 3.5-9.6 percent increase in preference adherence for clinicians using an EHR with an advanced care planning tab.

Although this was an improvement, the researchers conceded that it is not on its own adequate to ensure providers follow patient end-of-life preferences.

“Standardized documentation of preferences in the EHR is necessary, but not sufficient, for ensuring that end-of-life care is patient-centered,” the researchers concluded. “An important concern not addressed here is the quality of advanced care planning conversations, particularly in terms of informed consent and an ongoing dialogue that addresses patients’ changing circumstances.”

Therefore, it is important providers take all elements of advanced care planning – interpersonal relationships and utilization of health IT – as multiple pieces of the same puzzle. Without incorporating all of them, advanced care planning may fall short.