Skip to content

Advance Care Planning (ACP)

Description:
ACP allows patients to express preferences for care decisions if they lose capacity.
Methods include:
- Advance directives (living wills [LWs], health care durable power of attorney [DPOA]/medical power of attorney [MPOA])
- Physician/medical orders for life-sustaining treatment (POLST/MOLST)
- Facilitated conversations with family/significant others

ACP supports patient-centered care, especially with aging populations, new chronic diagnoses, or severe acute illnesses (e.g., COVID-19). It aids interpretation of wishes, negotiation of conflicts, and aligns care with personal values.

Definitions

  • Advance Directives: Written instructions guiding decision-making when patients lack capacity. Includes LWs and MPOAs.
  • Living Wills (LWs): Explicit written instructions on medical care preferences. Vary by state laws; some states have alternative forms. LWs do not prevent life-sustaining treatments in emergent settings (unlike POLST). Can be revised, do not expire.
  • Medical Power of Attorney (MPOA): Designates surrogate decision maker trusted by patient. Surrogate should be familiar with patient's values and preferences.
  • Physician Orders for Life-Sustaining Treatment (POLST/MOLST): Medical directives guiding EMS/first responders in emergent situations; portable across care settings. Provide legal protection when followed. More likely to be followed than LWs.

When to Initiate ACP

  • No strict guidelines; age ~65 years is a reasonable time.
  • After new serious illness diagnosis or significant disease progression.
  • Should occur while patient has decision-making capacity.
  • Important for nursing home residents, dementia patients who may lack capacity.

Pediatric Considerations

  • ACP important but challenging in children with serious illness.
  • Provider fears of parental distress are unfounded; ACP can unburden parents and improve understanding and rapport.

Suggested Discussion Points

For All Adults

  • Assess willingness to engage; do not force discussion.
  • Identify desired surrogate decision maker.
  • Encourage informing trusted persons about health changes.
  • Discuss personal values and goals.
  • Document decisions clearly.

For Chronic, Serious, or Terminal Illness

  • Discuss disease natural history, progression, end-of-life expectations.
  • Examples: COPD (exacerbations, ADL decline, mechanical ventilation), malignancy (pain, feeding issues, side effects).

For Older Adults

  • Routine discussions around 65 years.
  • Repeat discussions if clinical status changes.
  • Provide resources for LWs and legal help.
  • Complete POLST/MOLST as applicable.

For Clinical Status Changes

  • Frequent hospitalizations/ER visits should prompt ACP discussions.
  • Consider palliative care and caregiver support.
  • Timely hospice engagement if desired.

Communication Tips

  • ACP conversations can be complicated by social, familial, cultural, spiritual factors; be sensitive.
  • Use motivational interviewing to assess readiness.
  • Avoid medical jargon; describe interventions in terms of impact on quality of life.
  • Initial discussions may introduce the topic; subsequent visits address specifics.

Ongoing Care and Reimbursement

  • CMS reimburses ACP discussions (CPT codes 99497 and 99498).
  • No limit on frequency of billing; no diagnosis required; directive completion not mandatory for billing.

Follow-Up Recommendations

  • No fixed schedule for revisiting ACP.
  • Reassess after new diagnoses or health changes.
  • Encourage displaying POLST/MOLST prominently for EMS visibility.

Patient Education Resources

  • National Hospice and Palliative Care Organization
  • National Institute on Aging
  • Aging with Dignity (Five Wishes)
  • American Bar Association Toolkit
  • Prepare for Your Care
  • MyDirectives (electronic ACP)
  • DeathWise (worksheets for ACP components)

Complications and Challenges

  • Often forms (LW, MPOA, POLST) are completed but not accessible to physicians.
  • Electronic health records may store documents but retrieval can be difficult.
  • ERs face uncertainty when patient wishes are unknown or documents unavailable.
  • POLST forms help avoid confusion.
  • Misunderstandings about DNR/DNI orders common; these can be reversed or differ between chronic vs acute situations.

References

  1. American Association of Retired Persons. Advance directive forms by state.
  2. Centers for Medicare & Medicaid Services. Medicare Learning Network: advance care planning.
  3. Bosisio F, Barazzetti G. Advance care planning: promoting autonomy in caring for people with dementia. Am J Bioeth. 2020.

Additional Reading

  • Aging with Dignity: Five Wishes
  • American Bar Association: Health Care Advance Planning Toolkit
  • Heyland DK: Engaging seriously ill older patients in ACP
  • MyDirectives
  • National Healthcare Decisions Day
  • National Hospice and Palliative Care Organization
  • Prepare for Your Care

ICD10 Codes

  • Z71.89 Other specified counseling
  • Z51.5 Encounter for palliative care
  • Z66 Do not resuscitate

Clinical Pearls

  • ACP is an important, yet underused, element of compassionate, comprehensive patient-centered care.
  • Barriers from patients: lack of knowledge, fear of burdening family, desire for physician to initiate discussion.
  • Barriers from physicians: discomfort with topic, lack of time.
  • Active ACP review and documentation reduce unwanted interventions in ER and inpatient settings.