A Model to Promote Clinicians' Understanding of the Continuum of Advance Care Planning

Dear Editor:

Although the importance of advance care planning (ACP) is gaining recognition, challenges to making ACP routine practice persist.^1,2 One of the biggest challenges we have faced in our system-wide implementation of ACP in an academic medical center is clinicians' reluctance. Clinicians often do not talk about end-of-life preferences until curative options are exhausted, and do not recognize that ACP is appropriate for any adult with decision-making capacity including those in good health. Providers' comments such as “my patients with benign disease don't need to do that” or “we don't want patients to get the wrong message” are illustrative of this misconception. To correct this misconception and promote proactive ACP in every practice, we developed a model describing the continuous process of ACP (Fig. 1).

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FIG. 1.

Continuum of advance care planning.

ACP is on-going conversations to understand persons' values and goals of care throughout their health trajectory. In our model, the vertical axis represents health trajectory from healthy to end of life. The width of the row indicates the proportion of patients appropriate for the indicated activity. The goal of ACP is that when end-of-life care decisions need to be made (the apex of the triangle) and the person is not able to make them, families and healthcare providers are prepared to make the decisions based on an understanding of the patient's values and preferences (through the activities in upper rows).

Conversations should start when a person is healthy. Hospital providers who admit patients should ask all patients who their surrogate decision maker(s) would be if they become too sick even for healthy adults having elective procedures or for labor and delivery. This question could also be an entrée to discussing code status ³ or completing an advance directive. In primary care settings, providers should encourage their patients to start an ACP conversation with their families and friends as part of healthcare maintenance. Those receiving specialist care for a more serious illness should be encouraged to do the same if they have not already, or to revisit their prior conversations and documents to see whether their values and goals have changed.

A key insight was that clinicians tended to conflate any kind of ACP, especially “goals of care conversation” with end-of-life decision making. In our medical center, ∼75% of goals of care conversations did not occur until the patient was in the ICU or unable to participate. We plan to adopt the language from the Serious Illness Care Program, ⁴ which promotes such a conversation at the outset of a serious, progressive illness. Offering medical orders for life-sustaining treatment (e.g., Physician Order for Life Sustaining Treatment [POLST]) to patients with advanced stage illness or progressive frailty in addition to advance directives is also recommended. End-of-life conversation and decision making are the last phase of the continuum that builds on the previous conversations instead of the first time these issues are discussed.

The model depicts ACP as an on-going process beginning well before the end of life. It also depicts that some ACP activities are not appropriate for all patients. This model has been helpful to describe the gradual process of ACP, assist healthcare providers to discern where in the health trajectory their patients are, and provide ACP assistance appropriate for the patient's current condition.