National Healthcare Decisions Day: How Can We Improve Advance Planning?

Tomorrow (April 16) is National Healthcare Decisions Day, a massive effort by national, state, and community organizations to highlight the importance of advance healthcare decision-making.

Over 80 percent of older adults recognize the importance of planning ahead -- for having a plan in place for healthcare decisions, who makes them and what decisions will be made -- in the event they can't do so themselves. Yet only a third have actually implemented such a plan: that is, signed an advance healthcare directive or done anything more than just had a brief conversation with a loved one ("I don't want to be hooked up to a machine!").

Why is the uptake on advance healthcare decision-making so slight? How can we do better?

In 2006, Congress requested that the Department of Health and Human Services (HHS) conduct a study on how best to promote advance directives. Two years later, HHS released the results of its study.

Although advance directives and advance care planning can be important tools to assist those facing the end of life, the report said, the evidence suggests that end-of-life decision making in the United States is often poorly implemented:

  • Patients often receive care that is inconsistent with their preferences.
  • Care that is inconsistent with a patient’s prognosis or preferences causes undue suffering and wastes resources.
  • Most people do not complete an advance directive; when they do, the documents often do not affect care because they are limited in applicability and legalistic or simply physically inaccessible.
  • The focus on preferences concerning life-sustaining treatments commonly proves to be too simplistic, and vague instructions are difficult to apply, often adding little to the way that proxies and clinicians approach care decisions.
  • Preferences stated within advance directives (or poorly orchestrated advance care planning) are often at odds with clinical circumstances or can even impede effective decision making.

Educational interventions to further knowledge of advance directives were found to be largely unsuccessful.

What has shown some success, according to the report, are approaches that emphasize intensive and community-wide interventions that involve collaborations among patients and providers and the entire community.

For example, the Respecting Choices intervention in La Crosse, Wisonsin, which included patient and provider education, and changes in documentation policies and practices in order to alter community expectations and provider standards of care, demonstrated a nearly six-fold increase in advance directive completion and a match between treatments received and dying patients’ wishes.

National Healthcare Decisions Day is a similar effort, but one engaged on a national level.

Patients should not rely on their primary care physicians to know their wishes for healthcare and end-of-life care. Medical care in a hospital, for instance, is not always or even not usually directed by the patient's primary care physician.

Uptake can be enhanced by improving the tools to facilitate the task. For example, in Tennessee the Department of Health has made freely available on its Web site easy-to-understand -- and easy-to-complete -- Advance Directive and POLST (Physician Orders for Life-Sustaining Treatment) forms that allow patients to name their health care agents and express their wishes clearly for the end-of-life care and treatment they would want, and not want.

Forms for advance healthcare planning in Tennessee can be downloaded from here: http://health.state.tn.us/AdvanceDirectives/.

For a checklist, 25 Suggested Topics to Discuss with Your Health Care Agent, visit this Web site at www.tn-elderlaw.com/Family_Resources/.

 

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