ADVANCE CARE PLANNING: Thinking Ahead About End-of-Life Care

Raymund Damian, MD

Recent advances in medicine are vast and amazing. Beginning with medical school, physicians are trained to save lives. Ongoing medical research seeks and finds treatments that decrease risks for chronic medical conditions, develops surgical procedures to correct physical anomalies, and creates cures for cancer. If patients are ill, the medical profession concentrates its efforts on finding ways to cure them and, in the most serious cases, to prolong and save their lives. A challenge that physicians face is how best to deliver care when all reasonable life-prolonging treatments have been exhausted or when terminally ill patients have decided not to pursue further therapy.

In 2015, the end-of-life discussion came to the forefront in California with the Legislature’s passage—and Governor Jerry Brown’s signing—of the End of Life Option Act. The new law comes into effect on June 9, 2016. It allows physicians to go beyond providing comprehensive information and counseling to terminally ill patients regarding end-of-life options, which have traditionally been limited to palliative treatments. It now also allows physicians to accede to the request of such patients to be helped—with the prescription of an aid-in-dying drug—to end their lives when they choose.

Whether people agree with the principles and intent of the law, they are now having an open dialogue about end-of-life. A 2012 report by the California Healthcare Foundation showed that 79% of patients wanted to talk to their physicians about end-of-life issues, but only 7% of them actually did.¹ Physicians have been reluctant or unable to have these discussions for a variety of reasons, but now they have a responsibility, and more importantly, an opportunity to do so.

But even before such delicate and in-depth end-of-life conversations occur, the medical community has a responsibility to inform patients about advance care planning and engage them in it early on. Patients have their individual paths of health and trajectory of life. Discussing advance care planning more “upstream” can significantly affect how patients view and choose their care well in advance of death’s becoming imminent.

Advance care planning is a systematic approach that encourages patients to reflect on their values, beliefs and goals regarding a healthy life and to decide how medical care should be delivered when life’s trajectory is altered. Since 2013, Kaiser Permanente Northern California has implemented advance care planning through its Life Care Planning program. This program is a three-step staged approach that allows adult patients to make important medical decisions in advance of need. It encourages them to have an open dialogue with their physician and to share their decisions with family and friends.

The initial phase of the Life Care Planning program is called First Steps: My Values. Patients reflect upon and choose a reliable health care agent—a person whom patients trust, who will respect their values and wishes, and who can make sound medical decisions at difficult times. A result of First Steps is the completion of a thoughtful advance directive.

The second stage (Next Steps: My Choices) invites patients with chronic progressive medical conditions who have had a significant functional decline in their health or a prolonged hospitalization review their goals regarding future treatment options. Along with their health care agent, patients reflect on and discuss a series of medical scenarios that might prevent them from returning to their baseline of good health. The product of Next Steps is a Treatment Preference document.

The final stage (Advance Steps: My Care) helps patients who are frail and elderly or have a life-limiting illness to reflect upon care when life-sustaining treatment options need to be addressed. Based on this discussion, patients and physicians complete a Physician Orders for Life-Sustaining Treatment (POLST) document.

With the End of Life Option Act, physicians now have an added layer of complexity to consider when terminally ill patients voice their wish to die on their own terms. Kaiser Permanente Northern California recognizes this legal responsibility and is actively engaging in conversations and meetings to develop and implement policies and procedures that will respect and honor such requests.

In addition to having these rich conversations in all three steps, an important component of the Life Care Planning program is to collect these medical decisions and completed documents to make them easily retrievable in patients’ electronic medical records for review and future use. Advance care planning should be a partnership between patients and the medical community. The goal of Kaiser Permanente Northern California is to educate all physicians and staff about Life Care Planning and encourage them to discuss advance care planning with all adult patients who visit any Kaiser Permanente medical center.

To date, a review of the Life Care Planning program at Kaiser San Rafael has resulted in 1,426 First Steps encounters, 92 Next Steps conversations, and 1,030 Advance Steps (POLST) discussions.² The Life Care Planning program is an active component of patient care throughout the medical care continuum. The hope is that all health plans in Marin County will adopt and implement their own advance care planning program so that every adult patient’s medical decisions are honored and acted upon with respect.

---

Dr. Damian is co-MD lead of the Life Care Planning Program at the Kaiser San Rafael Medical Center.
Email: raymund.m.damian@kp.org

References
1. California Healthcare Foundation, “Final Chapter: Californians’ attitudes and experiences with death,” CHF report (2012).
2.Internal data of Life Care Planning at Kaiser Permanente San Rafael Medical Center.