During a crisis or pandemic, thoughtful advanced care planning decisions can be difficult to make, yet COVID-19 has brought this topic front and center. Advanced care planning involves learning about the types of decisions that need to be made, considering those decisions ahead of time, and putting them into an advanced directive. Many people mistakenly believe advanced directives are reserved for terminally ill or elderly people. Advanced directives are tools that give patients of all ages and health status the opportunity to express their values, goals for care, and treatment preferences to guide future decisions about their healthcare. Advanced directives also support continuity of care for patients when they transition across care settings, physicians, and care teams. It is advisable that clinicians also approach their own life planning decisions in the same way.
Use a Tool to Facilitate the Conversation
To facilitate the advance care planning conversation, clinicians may want to employ the assistance of a tool such as the “what matters most letter.” The letter template developed by the Stanford Medicine Letter Project can be found here. Although the letter is not binding, it gives guidance as the patient enters into the advanced directive process. The goal is to have a conversation with the patient in advance of a medical situation that renders them unable to make healthcare decisions. The letter encourages patients to talk openly about the following topics:
- What matters most to the patient
- How the patient and family make decisions
- How the patient and family handle bad news
- Who the patient wants to make medical decisions
- What the patient does and does not want
- How to resolve conflict about a treatment decision
- The patient’s thoughts about palliative sedation, including being put on or taken off a ventilator
- Donation of organs, tissues, and eyes
Another important document to discuss with your patients is whether or not they have a current advanced directive. There are two main elements in an advanced directive—a living will and a durable power of attorney for healthcare. A living will describes the amount and kind of medical treatment the patient wants under specific conditions. A durable power of attorney for healthcare is a written legal document that appoints an agent to make decisions about your health should you no longer be able to communicate. Every state has specific criteria for creating advanced directives; therefore, patients should seek legal counsel when drafting the document. An example of an advance directive can be found here.
Risk Management Recommendations:
- Educate yourself and staff on the importance of advance care planning. It can be a complex process, and it is best conducted when one is not facing a crisis.
- Create a protocol with talking points that requires your practice team to initiate a conversation with patients about advance directives. Document the conversation in the chart.
- Ascertain whether the patient has an advanced directive, and if so, whether it is current.
- If they do not have an advanced directive, provide the “what matters most letter” and ask the patient to return it during their next visit. Patients may feel more comfortable writing the letter outside of the practice.
- Place a copy of the “letter” or advanced directive prominently in the patient’s medical record.
- Encourage patients to share their medical preferences with their designated agent and family.
- On an annual basis, check-in with patients to see if they would like to update their “letter” or advanced directive. Patients often change their mind when there is a change in their health status.
For more information and resources on the COVID-19 crisis, please visit the COVID-19 Resources section of the KAMMCO Risk Management Tools and Resources page.
This document should not be interpreted as medical or legal advice. Because the facts pertaining to your situation may fluctuate, or the laws in your jurisdiction might vary, please contact your attorney if you have questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.
AMA Code of Medical Ethics. (2017) 5.2 Advanced Directives. American Medical Association. Retrieved April 13, 2020, from https://policysearch.ama-assn.org/policyfinder/detail/advance%20directive?uri=%2FAMADoc%2FEthics.xml-E-5.2.xml
Advance Care Planning: Healthcare Directives. (2017). National Institute on Aging. Retrieved April 14, 2020 from https://www.nia.nih.gov/health/advance-care-planning-healthcare-directives
Stanford Medicine (n.d.) Stanford Medicine Letter Project. Retrieved April 14, 2020 from http://med.stanford.edu/letter/what-matters-letter.html
Periyakoil, VJ (2016) End of Life Care: Facilitate Early Conversations With Patients. AMA Steps Forward Team Based Learning. Retrieved April 15, 2020 from https://edhub.ama-assn.org/steps-forward/module/2702695#section-217792964