Advance care planning; we need to do it more, but it needs to be done differently

Abstract

Central to the patient-centered care movement, is that medical care provided to patients should be aligned with their values and treatment preferences. This requires that patient values and preferences are known and are authentic and informed as well as being accessible by the treating clinical team when decisions have to be made. Advance care planning (ACP) is one tool to enable patients (and/or their legal representative or next-of-kin) to pre-determine their values and preferences and document them in a way which facilitates patient-centered care. ACP has been shown over the years to improve concordance between patient preferences for use (or non-use) of life-sustaining treatment and actual care received [1].In this article of EClinicalMedicine, Knight and colleagues [2] have provided a national snapshot on the accessibility of ACP at the point of medical decision-making for the UK. They audited a total of 123 hospitals in the UK and found, of all acute care admissions that approximately 5% had advance care plans available to the admitting medical team. This percentage was only slightly higher if the patients being treated were greater than 90 years old (12%) or were admitted from a long-term care facility (25%). These data are consistent with public polling data from Canada, where less than 20% of citizens had fully engaged in ACP [3]. The lack of a standardised definition of ACP and a standardised form to record the outcome of these planning conversations is a limitation of this work. But even in settings where such standardisations are in place, compliance rates are suboptimal [4].Remarkably, in the above study, of hospital readmissions of patients aged 90 or more, only 15% had an advance care plan. This was such a lost opportunity for these older patients (or their surrogates), not being engaged in high quality planning discussions while in hospital or shortly after discharge. Consequently, most of these older patients are not likely getting 'patient-centered care' or the medical care that is right for them. In such a clinical context, we have * Corresponding author.

Patient perspectives on states worse than death: A qualitative study with implications for patient-centered outcomes and values elicitation

“…This more generalized finding complements previous evidence that soliciting views on "unacceptable conditions" may elicit values among patients being evaluated for left ventricular assist device surgery. 26 The need for efficient and reliable methods to elicit patients' values and treatment preferences, particularly for the purposes of advance care planning, has been emphasized for years, [27][28][29] and has only been underscored during the coronavirus disease 2019 pandemic. 30,31 A key result of this study is that many patients define states worse than death as any condition that will overly burden their loved ones.…”