Canadian Society of Palliative Care Physicians recommendation#2: Do not delay advance care planning (ACP) conversations.
Choosing Wisely Canada: Recall and describe a clinical encounter in which you were called on to choose wisely.
Dr. Janet Reynolds: I recently accepted the wife of one of my patients into my practice. They are both in their 80s, very independent, and fearful of coronavirus disease 2019 (COVID-19). In our meet and greet, while updating her profile in her electronic medical record (EMR), I broached the topic of ACP. While she had previously been very healthy, owing to the uncertainty surrounding the COVID-19 pandemic, she was quite open to having the discussion.
CWC: In your exchange with the patient, how did you raise the need to choose wisely?
JR: Proactivity and opportunity: I took advantage of a meet and greet to broach the conversation. However, during the COVID-19 pandemic, we have been proactively using our EMRs to generate lists of potentially vulnerable patients. Our nurses are telephoning these patients to conduct wellness checks and will opportunistically broach ACP. If a patient is ready to explore this further, the nurse would offer them information and set up a virtual visit to have a more in-depth conversation.
Using your EMR: We have created a template to document our ACP discussions and, from a quality improvement perspective, this has allowed us to track who we have had conversations with. Additionally, our EMR flags the chart of any patient older than age 80, or those older than age 60 with chronic obstructive pulmonary disease, heart failure, or diabetes; this reminds the physician to consider initiating an ACP discussion.
Education: As I broached the ACP discussion with the described patient, she indicated that she did have a will. I often find patients confuse ACP with other elements of end-of-life planning, which I help to clarify. Patients also tend to understand basics such as cardiopulmonary resuscitation, but I will then explain that ACP involves more than that. For simplicity, I often discuss “life support” and “everything but life support” and explain the differences.
Also, importantly, I encourage patients to select a substitute decision maker and I ask them to speak with whomever they are naming about their wishes going forward. If a patient is young and healthy, I tend to lean toward focusing on this in case of an unexpected or traumatic event.
CWC: What are the key elements of the communication that made it a success?
JR: Understanding your patient’s context: Knowing your patient’s context is key. So, if they have a loved one who has died recently, it might be the right time to initiate those discussions, depending on where they are in their grief process. Similarly, if a patient was discharged from hospital recently, it might be the right time to reinitiate the discussion. Patient concerns surrounding the COVID-19 pandemic have also helped to start this conversation.
Using multimedia: As a clinic, we have started using webinars directed toward our patients to offer education about topics such as ACP. In our ACP webinar, our doctors role-play an ACP conversation and discuss details that can be challenging to cover in a single visit. It is important to remember that our physicians and practices are trusted sources of information for our patients. In addition to our website, we have hard-copy material for our patients who might not have easy access to the Internet.
Conversation over time: Advanced care planning is not a single-visit issue, and if I sense that patients need more time to digest the information discussed, I will provide them with our educational material and book a follow-up appointment. Additionally, it is a conversation that needs to be revisited. If there is a considerable change in health status, it is important to know whether a patient’s wishes have changed. Starting this conversation and ensuring there is an ongoing dialogue is critical in the event of a meaningful change to our patient’s life or health status.
This article first appeared in Canadian Family Physician. This interview was prepared by Dr. Aaron Jattan, Department of Family Medicine, University of Manitoba, for Choosing Wisely Canada.