Advance Care Planning

1. Types: Concepts in Advance Care Planning
   1. Advance Directive
   2. Provider's Orders for Life Sustaining Treatment (POLST)
   3. Do-Not-Resuscitate (DNR)
   4. Durable Power of Attorney
   5. Living Will
   6. Medical Directive
2. Protocol: Process for Advance Care Planning
   1. Document patient's values and cultural beliefs
   2. Determine health care preferences when patient healthy
   3. Patient selects Durable Power of Attorney
   4. Ongoing dialog with patient and their family
3. Approach: Gradual introduction for patients regarding Advanced Directives
   1. Routine patient visits at ages 50 to 65 years old
      1. Provide Advance Directive forms
         1. Consider mailing prior to preventive health visits
         2. Consider including as link from online appointment scheduling
      2. Review forms and answer questions at each routine physical exam
         1. Consider referral to clinic nurse for discussion
         2. Consider group sessions for education about Advance Directives
      3. Dialogue example
         1. "How would you like to be cared for if you had a devastating injury or illness"
   2. Diagnosis and maintenance of progressive chronic disease
      1. Discuss how health changes have impacted patient's Advance Directive goals
      2. Update forms to account for these changes
   3. Increased frailty and dependency (e.g. Nursing Home admission)
      1. Discuss prognosis and patient's Advance Directive goals
      2. Discuss Resuscitation and life support options
      3. Update forms
4. Resources
   1. Lynn: Improving care for the end of life
      1. http://www.medicaring.org/educate/
   2. National Hospice and Palliative Care Organization
      1. http://www.partnershipforcaring.org
5. References
   1. Spelhof (2012) Am Fam Physician 85(5): 461-6
   2. Sudore (2010) Ann Intern Med 153(4): 256-61