I recently tuned into Mettle Health’s online discussion “Advance Care Planning: Conversations and Documents”. Mettle Health, led by physician and author B.J. Miller, provides online palliative and holistic care. I highly recommend you check them out. B.J. was in discussion with UCSF geriatrician and palliative medicine physician Rebecca Sudore who has created a valuable Advanced Care Planning (ACP) resource at PREPARE For Your Care.
I thought I knew a lot about advance care planning; and I do, but I still gleaned important takeaways from the discussion. I was surprised to hear Dr. Sudore report that the percentage of people with a written ACP has held fairly flat over the past ten years at around 35%. However, Dr. Sudore noted that conversations about advanced care preferences have increased much more than the data would indicate.
As a practicing physician, Dr. Sudore noted that clinicians will generally follow written orders. But written directives can’t cover every situation. Even with a written directive, Clinicians often will defer to someone who can speak on behalf of a patient. Ideally, this person will be legally authorized by an ACP, Healthcare Proxy, or other form meeting state-specific requirements. In the absence of a legal appointment, clinicians default to State-specific hierarchies.
Which brings me back to the title of this blog. Dr. Sudore stressed that having conversations and making your wishes known to someone who can act for you can be more important than a written ACP. However, unless someone has been legally appointed, clinicians must follow state hierarchies which usually dictate that a clinician can only consult with family members. Bottom line: legally appoint someone (especially if you’d like to appoint a non-family member), and make your preferences known to that person.
A final takeaway. Dr. Sudore addressed controversial findings of a recent JAMA article, “What’s Wrong with Advance Care Planning”. The article asserts that ACP has not led to significantly better patient outcomes or lower medical costs. Dr. Sudore’s first critiquewas that the article’s conclusions were narrowly based on clinician-driven ACP, not patient initiated conversations and planning. Secondly, Dr. Sudore cited studies that show that ACP has an overwhelmingly positive impact on loved ones, surrogates and clinicians, reducing the anxiety and stress that come with having to make end-of-life decisions for someone.
To increase the likelihood of a GoodEnding, appoint someone to make healthcare decisions for you when you cannot (and one or more backups) and make your preferences known.