Advance Care Planning and Patient Care

When an emergency strikes, patients may be unable to communicate their preferred treatment and care methods. An advance care plan outlines these preferences and ensures all relevant parties, including doctors, nurses, and family members, are acutely aware of a patient’s feelings toward cardiopulmonary resuscitation (CPR), intubation, and more.

Advance care planning is a form of end-of-life care planning often associated with a living will. While a living will is one of the most prominent aspects of advance care planning, it is not the only one. Power of attorney, portable medical orders, and do not resuscitate (DNR) orders all play a part in the advance care planning process. With the right documents in place, patients are empowered to receive the care they want and deserve.

What Is Advance Care Planning?

The objective of advance care planning is simple: to ensure that every patient receives care that aligns with their values, personal preferences, and cultural and religious beliefs. It can take a variety of forms and address numerous emergency medical treatment options.

Here are some of the most common and effective advance care planning documents that a patient can put in place:

• Durable Power of Attorney

Some individuals, whether they are chronically ill or simply trying to be proactive, may decide to designate a durable power of attorney. A durable power of attorney is a legally recognized surrogate (typically a trusted relative) who makes healthcare decisions on behalf of a patient.

Most individuals will describe their emergency care preferences in detail to their power of attorney, arming them with the information they need to make medical decisions that align with the patient’s values and preferences. Those who choose not to have these discussions are relying on the individual they designated power of attorney to make healthcare decisions based on what they believe is in the patient’s best interest.

• Living Will

A living will is perhaps the most well-known type of advance care document. While a traditional will serves to enumerate an individual’s wishes after death, a living will outlines the actions they want medical professionals to take — and not take — in an emergency, end-of-life situation. It is a legally binding document that allows patients to rest assured that their desires will be met during end-of-life treatment.

Numerous documents can be included in a living will, including a DNR  order, instructions on when a ventilator is permitted, and details on post-mortem organ donation. Many individuals find the idea of writing a living will intimidating — especially when end-of-life care seems so far away — and worry about making the right decisions. Fortunately, a living will can be updated at any time to align with a patient’s wishes as they evolve.

• Do Not Resuscitate Orders

While DNRs can be included as part of a living will, they can also stand alone. DNRs are produced by a physician and inform healthcare professionals that the patient does not want CPR performed if their breathing or heart stops.

Patients who are nearing the end of their life or have a chronic condition that will not improve may opt for a DNR as a way to prioritize their comfort over their life expectancy. Some patients opt to wear a DNR bracelet or obtain a DNR wallet card to ensure all healthcare professionals, including members of a hospice team, emergency responders, etc., are aware of their wishes.

• Physician Orders for Life-Sustaining Treatment (POLST)

A POLST is a portable medical order produced by a healthcare provider to illustrate a patient’s medical care preferences. A POLST has varying names depending on the state a patient resides in. Medical orders for life-sustaining treatment (MOLST), clinician orders for life-sustaining treatment (COLST), transportable orders for patient preferences (TOPP), and medical orders for scope of treatment (MOST) are just a few of the many terms used to describe this type of order.

POLSTs are designed specifically for individuals who are critically ill and approaching the end of their life, whereas living wills can be implemented by all individuals, regardless of their current health status. A POLST addresses a very limited number of critical medical decisions and often accompanies other advance care directives. It also travels with the patient, informing healthcare professionals within nursing homes, hospice centers, and beyond of a patient’s end of life preferences.

How Does Advance Care Planning Improve Patient Care?

Advance care planning is ultimately a means of improving patient satisfaction. Advance care directives help patients minimize surprises associated with their medical treatment and keep healthcare professionals abreast of each patient’s unique end-of-life healthcare preferences. They also increase patients’ trust in the healthcare system by empowering them with the autonomy to identify their course of treatment.

Because advance directives are living documents, patients can review and revise them at any given moment. This allows patients to rest assured knowing that their first directive is not irreversible and that their healthcare preferences can evolve as they age.

In addition to providing peace of mind and improving autonomy, advance care planning can also decrease acute care admissions for end-of-life patients, as many patients will leverage advance directives to outline their desire to avoid surgical procedures and life support. In some cases, advance care planning statistics have demonstrated a link between advance care planning and net cost savings, due in part to terminally ill patients requesting at-home hospice care versus more costly inpatient care.

Why Is Advance Care Planning Important for Providers?

In addition to the many patient benefits it provides, advance care planning also has tangible benefits for providers. The advantages of advance care planning for providers include improved quality of care and higher satisfaction ratings among patients and their families.

Healthcare providers are constantly looking for new ways to improve patient care. Advance directives allow these professionals to understand exactly what their patients want, without any guesswork.

While patient satisfaction is not always reflective of the quality of care provided — in most cases, healthcare professionals must do everything possible to improve a patient’s health, even when a patient may find a procedure uncomfortable — it is particularly relevant in end-of-life care. When a variety of approaches will almost certainly yield the same mortality outcome, the quality of care becomes increasingly dependent on patient care preferences.

Improved patient satisfaction is also important from a legal standpoint. Crisis scenarios often raise tensions among patients’ family members, and without an advance directive, it is all too common for people to disagree over the best course of treatment for a patient. In a worst-case scenario, a patient’s relative may seek legal action against a hospital due to an end-of-life medical decision that they believe wasn’t the right choice.

Advance care planning can significantly reduce the amount of stress, time, and energy providers spend explaining the efficacy of a treatment to a patient’s loved ones. With an advance directive, there is no doubt as to what course of treatment the patient wants.

Advance care planning also helps improve communication between all members of the healthcare team. In a moment of crisis, doctors and nurses must approach patient care with a unified, streamlined solution. This can be difficult to do when multiple courses of treatment are viable. A clearly defined advance directive serves as a compass, assuring doctors and nurses that they are taking the right course of action in an emergency.

What Are Some Limitations of Advance Care Planning?

While advance care plans offer plenty of benefits to patients and providers alike, you should be aware of advantages and disadvantages to advance directives. A well-rounded discussion of the advantages of care plans of this type must also acknowledge the limitations inherent in them. Fortunately, many of the disadvantages of advance care planning can be remedied with simple improvements.

The most prominent concern regarding advance care directives is that no standard approach exists for implementing one. While some hospitals have medical professionals with advance care planning experience on staff, allowing them to better guide patients through the advance care planning process, many do not. As a result, some patients are informed about advance care options early, while others may be left on their own to inquire about their advance care options.

Discrepancies in advance care education among healthcare professionals can also limit the effectiveness of a hospital’s advance care planning process. Many medical professionals are only vaguely aware of the various advance care directives available to patients and the nuances of each, leading to missed opportunities for successful advance care planning.

How Can Healthcare Professionals Improve Care Plans?

Healthcare providers — especially those working in the palliative care field — can greatly improve patient satisfaction by expanding their understanding of advance care planning and advance directives.

While hospital administrators are responsible for improving advance care planning on an institutional level, individual healthcare providers have plenty of opportunities to promote and increase the effectiveness of advance care planning among their patients.

Improving Your Advance Care Planning Process

For many healthcare providers, improving the advance care planning process starts with education. Only once they have a keen understanding of end-of-life care, including the varying advance care directives available, ethics in critical care scenarios, and ways to improve communication with patients and their family members, can healthcare providers successfully lead patients through the advance care planning process.

Education in advance care planning can take numerous forms, depending on the structure of the training plan. Online continuing education courses, in-person advance care planning workshops, and collaborative team meetings are all productive ways for healthcare providers to learn more about the nuances of advance care planning.

When a hospital implements a unified advance care planning program, every member of the care team is equipped with the skills they need to improve patient care and boost satisfaction ratings. With proper training, providers can gain the communication skills and knowledge base they need to help their patients make difficult, but important, decisions about their healthcare.

Improving advance care is not as simple as encouraging patients to fill out a living will. Providers must tactfully empower patients to prepare for their future with confidence.