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    Advance Care Planning

    Basics

    Description

    • Advance care planning (ACP) refers to how patients make decisions about care they will receive if they can no longer speak for themselves.
    • Several methods address uncertainty of goals of care as patients age, these include:
      • Advance directives, living wills (LW), heath care powers of attorney, physician/medical orders for life-sustaining treatment POLST/MOLST forms, and facilitated conversations with family and significant others
    • ACP is an important aspect of patient-centered care that has become more important as the population ages and people lose decision-making capacity.
    • Interpreting patient wishes in the context of individual illness circumstances, negotiating conflicts in decisions, and aiding patients in determining what is in their best interest based on personal values can be challenging.
    • Definitions
      • Advance directives (1): written instructions in the form of a LW, a health care durable power of attorney (DPOA) appointing a health care proxy (HCP), or other medical directive (e.g., Five Wishes) to guide decision-making in the event that a patient is unable to provide informed consent
        • LW and DPOA usually only take effect if the patient has been determined to lack capacity to decide care for him or herself; otherwise, patient preference takes precedence even if it contradicts a LW.
      • LW: written instructions of a patient’s wishes regarding medical care
        • Each state has laws governing notarization and witness requirements for the LW to be a legal document. Certain states do not recognize LW but have specific “medical directive” forms. LW and medical directives can take effect immediately (e.g., when a patient is diagnosed with a terminal illness) or when a patient can no longer make decisions for him or herself.
        • LW have the benefit of using direct instructions regarding treatment wishes.
        • LW challenges include lack of standard format, completion far in advance of use, narrow scope.
        • LW do not expire but they can be revised.
        • The LW is NOT a medical directive, so it cannot prevent emergency medical services (EMS) from providing life-sustaining treatment as a POLST can (see below).
      • DPOA: a written document designating a surrogate decision maker in the event the patient cannot speak for him or herself
        • An HCP speaks for the patient and makes decisions aligning as closely as possible to the patient’s wishes. Ideally, this is someone the patient knows well and trusts and who has had discussions with the patient about his or her values.
        • If multiple HCP are named, disagreements about who speaks for the patient must be resolved before a decision can be made.
        • If there is a conflict between a LW provision and a HCP decision, different states have varying rules regarding precedence. In some states the DPOA supersedes the LW; in other states the most recently executed document is legally binding.
      • POLST/MOLST: a medical directive, which (unlike LW) directs point of care decision-making by EMS for patients in advanced stages of illness
        • This is an adjunctive document to LW and DPOA as it provides clear instruction regarding resuscitation, intubation, and treatment options to minimize confusion.
        • These documents are portable and follow a patient across different care settings. Given their simplicity, POLST/MOLST is more likely to be followed than LW, which can be difficult to locate.
        • Although EMS may be concerned about the legal implications of withholding life-sustaining treatment, POLST forms provide legal protection if patient wishes are followed.
        • Studies have shown that patients with active POLST have fewer unwanted interventions.
    • Nursing home residents and demented patients often do not have capacity to complete legal documents related to LW and DPOA.
    • Primary care physicians should address ACP when patients are able to make decisions about their future care.
    • There are no guidelines for when to initiate discussions about ACP, but age 65 years may be an appropriate time for a realistic conversation prior to the onset of dementia or incapacitating illness.
      • Each conversation needs to be individualized based on patient’s willingness to engage.
      • A specific age threshold does not account for debilitating accidents earlier in life or disease processes that have a faster progression to morbidity and mortality.
    Pediatric Considerations
    • Pediatric ACP (pACP) is less common. For children with serious acute or terminal illness, it is a difficult (but important) part of treatment.
      • Provider fears about increasing parental distress when discussing pACP are unjustified.
      • pACP may unburden parents regarding difficult decisions and is associated with increased positive emotions, understanding of the patient’s illness, and provider rapport.

    Treatment

    • ACP discussions are often complicated by various emotional, cultural, and medical factors. It is important to engage in these conversations with sensitivity about the patient’s frame of reference and understanding about his or her health status.
      • African Americans are less likely than whites to complete AD. Preference for life-sustaining treatment, religiosity, poor health literacy, and distrust of the medical community all contribute to this difference.
    • Do not force the conversation if a patient is resistant or unprepared to discuss ACP.
      • Motivational interviewing can be used to gauge interest and readiness to discuss ACP.
      • Addressing implications for friends and family who may be burdened with decision-making may help promote ACP conversations.
    • The first time ACP is brought up may serve as an introduction to the topic as well as an opportunity for the patient to consider options. Subsequent visits can address specific scenarios and choices (2).
    • Use specific lay terminology when addressing medical conditions and options. Patients may not understand the severity of illness or the implications of advanced life-saving interventions (CPR, mechanical ventilation, parenteral nutrition, etc.).

    Ongoing Care

    Reimbursement: The Centers for Medicare & Medicaid Services has reimbursed physicians for ACP discussions since 2015.

    • The current CPT codes are 99497 for the first 30 minutes of discussion and completion of forms, and 99498 for each additional 30 minutes (3).
    • There are no limits to the number of times ACP can be reported in a given period of time.
    • An advance directive does not have to be completed in order to bill for services.
    • No specific diagnosis is required for the ACP codes.

    Follow-up Recommendations

    Patient Monitoring
    • There are no specific guidelines for how often a LW or DPOA discussion should be revisited after they are completed.
    • When there is a new diagnosis or a significant change in clinical status, it is prudent to have the patient consider how it would affect his or her ACP decision-making.
    • Have patients display POLST/MOLST form prominently so it is easily visible to EMS.

    Patient Education

    • The National Hospice and Palliative Care Organization, Aging with Dignity, National Healthcare Decisions Day, and the American Bar Association have online resources to help patients.
    • Online platforms such as My Directives allow patients to specify their wishes electronically.
    • DeathWise is a nonprofit organization with worksheets patients can use to help them with the health, financial, care of body, and service components of ACP.

    Complications

    • Often LW, DPOA, and POLST are completed but physicians do not have access to them. Electronic health records are a convenient place to store these documents but due to poor integration between systems, they may be difficult to retrieve.
      • When a patient completes an ACP form, it should be part of the medical record with open access (if possible) to facilitate appropriate decision-making regardless of location or system.
      • Medical bracelets or other devices are often used to notify EMS of patient directives.
    • Emergency rooms are vulnerable to uncertainty about what interventions patients want if they cannot communicate for themselves.
      • POLST forms should accompany patients if possible to avoid confusion.
    • There is often misunderstanding on the part of both doctors and patients regarding do not resuscitate (DNR) and do not intubate (DNI) orders.
      • DNR/DNI orders can be reversed or should not be honored in certain situations. DNR/DNI in a person with a chronic progressive illness does not necessarily mean DNR/DNI for an acute reversible process.
      • The prognosis for successful resuscitation on a hospital ward is approximately 14%; it is 50–80% for patients undergoing surgery.

    Additional Reading

    Codes

    ICD-10

    • Z51.5 Encounter for palliative care
    • Z66 Do not resuscitate
    • Z71.89 Other specified counseling

    ICD-10

    • V49.86 Do not resuscitate status
    • V66.7 Encounter for palliative care
    • V68.89 Encounters for other specified administrative purpose

    SNOMED

    • 103735009 Palliative care
    • 143021000119109 Do not resuscitate status with supporting documentation
    • 3011000175104 Active limitation of emergency treatment
    • 3021000175108 Active heathcare surrogate
    • 3031000175106 Advance healthcare directive requested
    • 3041000175100 Active five wishes
    • 3051000175103 Advance directive information unavailable
    • 3061000175101 Advance directive infomation pending evaluation
    • 306237005 Referral to palliative care service
    • 310301000 Advanced directive status
    • 310302007 Advance directive discussed with patient
    • 310303002 Advance directive discussed with relative
    • 310305009 Active advance directive (copy within chart)
    • 425392003 Active advance directive
    • 425393008 Active Durable Power of Attorney for Healthcare
    • 425394002 Active healthcare will
    • 425395001 Active living will
    • 425396000 Active advance directive with verification by family
    • 425397009 Active advance directive with verification by healthcare professional
    • 449441000124105 Durable power of attorney for healthcare
    • 449891000124104 No advance directive
    • 4901000124101 Palliative care education
    • 697978002 Provider orders for life-sustaining treatment
    • 713058002 End of life care planning
    • 713281006 Consultation for palliative care
    • 713580008 Review of advance care plan
    • 713581007 Review of advance care plan offered
    • 713602009 Discussion about end of life care planning
    • 713603004 Advance care planning
    • 713604005 Education about advance care planning
    • 713662007 Discussion about advance care planning
    • 713665009 Discussion about advance care planning with family member
    • 714361002 Discussion about advance care planning with caregiver
    • 714748000 Has advance care plan
    • 715016002 Advance care planning request by patient
    • 718637005 End of life care planning offered
    • 87691000119105 Comfort care only status

    Clinical Pearls

    • ACP is important and underutilized.
    • The primary barriers to discussing advanced directives in the primary care setting from the patient perspective include lack of knowledge, fear of burdening family, and the desire for physicians to initiate the discussion.
    • The primary barriers from the physician perspective include discomfort with the topic, lack of emotional support, lack of reimbursement, and lack of adequate time to fully address the topic.

    Authors


    Christopher Lin-Brande, MD
    Heather A. Dalton, MD
    Amy M. Davis, MD

    Bibliography

    1. Advance directive forms by state. http://www.aarp.org/home-family/caregiving/free-printable-advance-directiv.... Accessed November 21, 2017.
    2. Spoelhof GD, Elliott B. Implementing advance directives in office practice. Am Fam Physician. 2012;85(5):461–466.  [PMID:22534224]
    3. Centers for Medicare and Medicaid Services. Frequently Asked Questions about billing the physician fee schedule for advance care planning services. https://www.cms.gov/Medicare/Medicare-fee-for-service-Payment/PhysicianFee.... Accessed November 21, 2017.


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    Citation

    Stephens, Mark B., et al., editors. "Advance Care Planning." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688009/all/Advance_Care_Planning.
    Advance Care Planning. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688009/all/Advance_Care_Planning. Accessed April 26, 2019.
    Advance Care Planning. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688009/all/Advance_Care_Planning
    Advance Care Planning [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 26]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688009/all/Advance_Care_Planning.
    * Article titles in AMA citation format should be in sentence-case
    TY - ELEC T1 - Advance Care Planning ID - 1688009 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688009/all/Advance_Care_Planning PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -