PRACTICAL CONCERNS: Got an Advance Directive?

Raymund Damian, MD

Imagine this scenario: A 76-year-old man with hypertension, type 2 diabetes and congestive heart failure is admitted for pneumonia. As the intravenous antibiotic and supplemental oxygen are being administered, physicians determine that the patient has impending respiratory failure. The admitting physician approaches the patient and his family about the possibility of intubation. The physician asks if an advance directive is available. The anxious patient cannot answer coherently, and his fearful family at the bedside states they are not aware of any documentation.

Many physicians have experienced this scenario in varying degrees. The need to review a patient’s advance directive almost always occurs when the patient is in a medical crisis. For most patients and physicians, a medical emergency is the first time an advance directive is addressed. This does not need to be the case.

In the last 50 years, judges and juries have ruled on several landmark cases involving a patient’s right to accept or decline life-sustaining treatments, including cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, continued intravenous fluid hydration, and medications. One outcome from these cases was passage of the Patient Self-Determination Act in 1990. This federal law requires all medical institutions to determine if a patient has an advance directive and to provide information about the patient’s right to refuse any medical treatment under the laws of the state and the policies of the medical institution. Many medical organizations and health plans have also made advance care planning part of their standard medical practice.

Despite these forward steps, the movement to integrate advance care planning as a component of regular health care has been slow. A recent report from the California Healthcare Foundation found that 82% of the state’s patients believe it is important to have end-of-life decisions documented in writing, but only 23% have actually completed an advance directive.¹ This disconnect can be attributed to patient misconception and apprehension and physician reluctance.

Healthy patients often think it is “too early” to talk about an advance directive. When the subject is approached later in life, many fear that something is terribly wrong with their health. Adding to this reluctance are physicians who hesitate to introduce this “sensitive” matter to patients, especially in a time-limited environment. This combination of perceptions and behaviors results in a failure to present advance care planning as part of regular health care. Discussing advance directives does not happen early enough, and for some patients, the discussion happens too late.

Advance care planning is a systematic approach whereby patients are able to reflect on their goals, values and beliefs regarding a healthy life and decide how medical care should be delivered when that life is suddenly altered. One result of this initial discussion is completion of a thoughtful and well-constructed document called an Advance Directive for Health Care.

There are several types of advance directive (e.g., estate plan, living will, durable power of attorney for health care), but the main elements are the same: naming an agent or agents as decision maker(s) when a patient is not able to make decisions independently and/or competently, and accepting or refusing life-sustaining treatments when the patient’s respiratory and circulatory functions are severely compromised. Some documents also address severe permanent brain injury.

To help patients feel comfortable addressing and completing an advance directive, the medical community is encouraged to embrace the concept more openly and to present the idea to patients during their healthy adult life. Presenting an advance directive early in patients’ lives allows them to reflect, revise and decide on important aspects of medical care when they experience a tragic or life-altering event.

One example of advance care planning in Northern California is Kaiser Permanente’s Life Care Planning program. The program is a three-step staged approach that allows adult patients to make important medical decisions as they go through life and encourages them to have an open dialogue and share their decisions with family and friends.

The initial phase of Life Care Planning (My Values: First Steps) helps patients reflect upon and successfully complete an advance directive. The second stage (My Choices: Next Steps) invites patients with chronic progressive medical conditions who have had a significant functional decline in their health or a prolonged hospitalization to review their goals regarding future treatment options. The final stage (My Care: Advanced Steps) helps patients who are frail and elderly or have an advanced or life-limiting illness to reflect upon end-of-life issues. Based on this discussion, physicians and patients complete the Physician’s Orders for Life-Sustaining Treatment (POLST) form. The entire program is designed to help patients, family and friends make constructive medical decisions throughout the patients’ trajectory of life.

Kaiser physicians have been educated about Life Care Planning and are encouraged to discuss the concept with their patients in a regular office visit. After the discussion of the first stage of the program, patients are invited to attend an advance directive class, make an appointment with a Life Care Planning staff member, or review the program via an online course. The goal is get every Kaiser Permanente patient, employee and physician to address and complete an advance directive.

Another goal of Life Care Planning is to educate the local medical community and implement advance care planning programs that invite and encourage every patient in every health plan to complete an advance directive. Success in advance care planning can be measured when a patient confidently and openly answers YES to this question: Got an advance directive?

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ADVANCE DIRECTIVE KIT AVAILABLE FROM CMA

California law gives patients the ability to ensure that their health care wishes are known and considered if they become unable to make these decisions themselves.

The California Medical Association publishes an Advance Health Care Directive Kit that includes an Advance Health Care Directive form and wallet cards, as well as answers to common questions about advance directives. The kit is also available in Spanish.

The kits are available in quantities from one ($5 per kit) to 200 ($1.50 per kit). Additional discounts are available for bulk orders.

To order, visit www.cmanet.org or contact the CMA Bookstore at 800-786-4262. Please allow 2–3 weeks for delivery. This item is not available for download from the CMA website.

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Dr. Damian, an internist at Kaiser San Rafael, co-leads the Life Care Planning Program at that facility.
Email: raymund.m.damian@kp.org

Reference
1.  California Healthcare Foundation, “Final chapter: Californians’ attitudes and experiences with death,” CHF report (2012).