Advance care planning is an underrecognized issue, but its status has been elevated during the COVID-19 pandemic.
This article was originally published March 22, 2021 on PSQH by Matt Phillion
It’s something many healthcare professionals and organizations are well aware of: Advance care planning and end-of-life preferences are an oft-overlooked part of patient care to be improved upon.
But it isn’t just about being aware of patient preferences. Ensuring every patient’s end-of-life care preferences are documented and accessible also works to reduce harm and improve patient outcomes.
A year living through a pandemic has made this issue even more abundant—older patients, and those with chronic conditions, have been among those most at risk for severe, life-threatening conditions, including those attached to COVID-19. And what happens when one of these patients is placed on a ventilator, unable to voice their wants in terms of treatment?
To avoid these scenarios, the industry needs to ensure providers, caregivers, patients, and families are engaged in advance care planning discussions.
“Providing goal-concordant care to individuals at end of life is absolutely a patient safety issue,” says Ryan Van Wert, MD, an intensive care physician, a part-time clinical assistant professor at Stanford University, and co-founder and CEO of Vynca, an advance care planning solution organization. “It absolutely fits into quality measures and value-based paradigms.”
Advance care planning is an underrecognized issue, but its status has been elevated during the COVID-19 pandemic, Van Wert notes. It rose to the forefront at the outset of the pandemic, making sure everyone’s voice was heard, he adds. “Certain demographics were at the highest risk, but I think the message was that nobody was really safe. Everyone had the potential to get seriously ill, and that brought it home to a lot of people.”
Our time with COVID-19 has forced many patients, families, and providers to reflect on what would happen if the unthinkable does occur. Do you have a mechanism through which your wishes could be honored?
“The challenge with advance care planning is in reality, it’s a very complex process to implement and scale in a high-quality, consistent way,” says Van Wert.
Unique challenges to implementation
To start, advance care planning isn’t something that should be done on the fly, Van Wert notes.
“These are difficult decisions. They take time,” he says. “And providers are often not trained for it. There’s often a default in healthcare that you do everything to save the patient until you’re instructed otherwise. It’s an aggressiveness of care.”
Physicians and other care providers, without the proper guidance of advance care planning, can only do what they believe is the right thing. And yet patients don’t often ensure their wishes are clearly documented.
“We know from the data that advance care planning for populations 65-plus is often in the single-digit percentages,” says Van Wert.
Hospitals and other healthcare organizations can step in to improve that number, though. Organizations like Vynca can work with hospitals by providing analytics to identify populations in need, offering providers the education they require to conduct the difficult conversations around advance care planning, and locating patients who need to have these conversations before they end up in an emergency situation.
Organizations need to realize that advance care planning—or the lack thereof—is a patient safety issue like any other, Van Wert notes.
“We look at issues like central line infections or wrong-site surgeries and address them by implementing standardized processes and protocols,” he says. “This applies to other areas of medicine, including delicate topics like advance care planning.”
The logical, scientific processes used to prevent other patient safety issues or medical error risks—workflow redesigns, custom messaging, change management, and business intelligence—can also come into play when tackling advance care planning, helping to implement change and measure success.
“It’s a way of looking at organizational change: Normalize dialogue and look at natural points to have these conversations,” says Van Wert.
Finding the right time
Clearly, a patient in distress is not in the best situation to consider their advance care preferences. A better opportunity to bring this topic up, Van Wert notes, is during Medicare wellness visits, when the patient and provider can have a frank conversation without the pressure of an emergent situation.
“It’s a matter of finding a natural point in the patient’s care when these conversations are appropriate and can have an impact on individuals,” he says.
It’s hard to determine exactly why these conversations don’t always happen. In some cases, patients may be uncomfortable outlining their wishes to their loved ones. In others, patients who are approached by a provider on the subject may feel like the provider is giving up, which is not the case either.
“It’s a multifaceted problem, and that’s why it’s been historically difficult to solve,” says Van Wert. “Our goal is, at an organizational level, to unpack those reasons and make it OK—to normalize it.”
There’s also the matter of time itself. There’s only so much time in the day, and often advance care planning is not considered pivotal enough to take it up. However, this is changing on the reimbursement side, signaling a greater understanding of advance care planning’s importance. CPT® codes and other payment structures now recognize the time it takes for providers to have these conversations.
“Advance care planning is a quality measure, and payers like CMS and others have recognized that,” says Van Wert.
If these conversations and their documentation are tied to financial performance, this means organizations can look at them from a strategic point of view. “Beyond quality of care, and knowing it’s the right thing to do, there are measures and payments that recognize the time involved,” says Van Wert.
Organizations are also starting to look more at who has those conversations. Often, the best person to sit down with the patient is not the physician, but rather another member of the interdisciplinary team. It might make sense, for example, for a nurse practitioner to have specific training in this area, identify patients coming into the office who need to have an advance care planning conversation, and build that conversation into a regular appointment.
“It’s important to make sure they’re equipped with the right tools and ensure their time is protected to have these conversations,” says Van Wert. “There are multiple ways to solve the problem of lack of time, and it comes down to how we make sure there’s a strategic reason to focus on this area, and then looking at the workflow, accountability, team formation, and ancillary services to make sure it’s done in a quality, consistent way.”
We also know through numerous studies, Van Wert notes, that a number of patients would see the value of palliative care if offered.
Understanding that patient preferences are a part of care quality is key to successful advance care planning. This means accepting the necessity of honoring patients’ wishes. It also means that failing to clarify or document an individual’s wishes is in fact a medical error, and medical errors predispose patients to an adverse event—in this case, over- or undertreatment.
Aligning the organization to these facts can help prioritize advance care planning as a program or initiative, which can prompt greater success as well as sustainability.
“It’s an enormous patient safety issue that’s been historically difficult to develop a business case to support, because of competing priorities,” says Van Wert.
The starting point for the benefits of advance care planning should always begin with a better patient experience, but on paper, there are a number of risks a proper focus on the issue can help alleviate.
Hospitals spend millions of dollars trying to optimize their mortality rates. “How do we make sure fewer people die in the hospital?” says Van Wert. With an advance care plan on file, the odds of dying in the hospital are 79% lower, and fewer readmissions are seen as well.
“The way to reduce a lot of these events is to make sure people who would prefer not be in the hospital are not,” says Van Wert. “Enable them to go into hospice or palliative care.”
Another trend to look out for: a rise in wrongful life cases. As mentioned earlier, healthcare organizations often default to sustaining life as a supposedly lower-risk decision. But more and more legal cases are being brought against organizations because a patient’s advance care planning documentation was not accessible or honored.
“A lot of organizations have underinvested in comprehensive advance care planning,” says Van Wert. “There’s a misalignment between the patient, the family, and the caregiver. If those conversations have been had but the documentation is not clear or accessible, that’s a medical error. It’s not just a problem of what happens in the ER—it’s if the organization has recognized the importance of this issue and recognized that the patient’s voice must be heard.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.
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