Reply to: Comment on: “Advance” care planning reenvisioned

Abstract

To the Editor: I appreciated Bradshaw and colleagues' interest in my recently published editorial. 1 As they correctly indicated, "this article challenged the current approaches to 'advance' care planning and proposed an alternative approach, adaptive care planning." 2 Bradshaw and colleagues raise several interesting points worth addressing.First, Bradshaw and colleagues believe that "In the context of COVID-19, …, there has been concern that focus on process goals (e.g., completion rates of ACP), …, and the general uncertainty that surrounds these discussions, have led to the anticipated benefits of ACP being questioned. In her recent editorial…, Moody expresses similar concerns…." 2 Of course, the concern about ACP goes beyond the COVID-19 pandemic. Yet, the demands for goals-of-care discussions in the context of the pandemic have highlighted some of the challenges ACP previously presented. 3 Perhaps the current pandemic provides an opportunity to codify adaptive care planning, wherein decision-making occurs in many moments, in response to unfolding clinical events and information, little by little while keeping an eye on the overarching future goal, even when that changes over time. 1 Second, I appreciate that Bradshaw and colleagues attempt to build on my idea of adaptive care planning by proposing "a hybrid approach to ACP" that "embraces ACP as a multi-component process and resists the false dichotomy of seeing ACP as either decisions made in the moment, or decisions made for the future." 2 This is a misinterpretation of the adaptive care planning I propose. The intent of my paper was not to indicate that there are "near" future and/or "in the moment" processes that should be separable. In fact, I am proposing an integrated, continuous approach, where "advance" decisions address the near future and "in the moment(s)" decisions that occur in cumulative multiple moments, as decisions made too far in advance poses multiple challenges highlighted in my editorial. Medical crises often take place over time, requiring multiple, iterative decision-making moments