The System to Implement Advance Care Planning and Make Proxies, Advance Directives, and Portable Medical Orders Available and Actionable Across Care Settings

Abstract

Few would debate that thoughtful advance care planning conversations between providers, patients, and patients’ loved ones reflect a respect for the right to direct one’s end-of-life care based upon personal values, preferences, and goals. Previous research suggests that advance directives and medical orders are the vehicles to enable patient wishes to be known. However, without ensuring clinician access to those documents, the chances that a patient will receive the desired level of treatment at the end of life diminish significantly. This chapter explores the impediments to accessing and acting upon advance directives and medical orders and suggests a comprehensive system that improves access to completed advance care planning documents for providers and patients. It reviews the successes with such a system in a state—West Virginia—and the positive outcomes with employing components of the proposed system with chronic kidney disease and dialysis patients.