Issue link: http://viewer.e-digitaledition.com/i/643923
ALTHOUGH COMPLE TION OF a liv- ing will, and in some states, a POLST ( physicia n order for life-susta ining treatment), are quality markers for hos- pita ls, insurers, and other hea lthcare organizations, form completion seldom sig nif ies ef fective com munication . EŸective advance care planning (ACP) requires the practitioner to understand medica l conditions, identify physica l, psychosocia l and spiritua l needs, esti- mate life expectancy, and elicit va lues. This process is more likely than a form a lone to a lign medica l goa ls and treat- ment burden with patient needs. T r e a t ment bu r den i s a g r ow i n g problem. Ninety percent of older adults have one chronic medica l condition, and three quarters have two or more. Guidelines recommend a multifaceted approach. Diabetics should have blood pressure, cholesterol and blood sugar control led. Each such i nter vention requires one or more diŸerent medica- tions. More than 40 percent of patients with diabetes have four or more other conditions. Ha lf of patients with heart fa ilure have five or more conditions. A mong the 13 percent of older adults with A lzheimer's disease, 40 percent have five or more conditions. Medication side eŸects ma ke it nearly impossible to prescribe four or more medications that do not interact with each other or with a dietary constituent. Prognosis and life expectancy are di«- cult as well. Luckily, diseases such as HIV and conditions such as metastatic breast cancer are now considered chronic rather than deadly, and metastatic colon cancer can be curable. However, coexistence of multiple chronic conditions a lone shortens life expectancy. Superimposing a serious disease, diagnosis, or even a fall on a patient with multiple chronic conditions may limit disease treatability. Additionally, physical, nutritional, and functiona l def icits a lter response to treatment and may lower life expectancy. Advance care planning is important to all adults. Younger, healthier adults should focus on identifying a proxy to make healthcare decisions for them in case of a serious event such as a fall, motor vehicle accident, etc. The patient should share personal values, including quality of life, longevity and acceptable burdens, with the healthcare proxy. A brief conver- sation and advice for a durable power of attorney for healthcare may be the only interventions needed. Adults with multiple chronic condi- tions or with one serious condition such as HIV or cancer, and all older adults should consider more comprehensive ACP. EŸective planning requires the time, patience and listening skills of the practitioner, usually over multiple visits. Although a change in function resulting from disease progression, hospitalization or trauma provide a natural opening, planning should begin earlier in the course of a patient's illness and be revis- ited as conditions change. Patients have fears, goals and priorities. Some may be willing to shoulder physical symptoms and assume substantial burdens includ- ing pills, dietary restriction and multiple doctor visits. Others are not willing to sacrifice independence and family time. ACP helps practitioners to individualize a medical plan. A lthough patients of geriatricians and palliative care practitioners usually receive substantial ACP, comprehensive ACP needs to be accessible to a wider popu lat ion . Med ica l , nu rsi n g , a nd advance practice nurse training pro- grams may benefit from using some of the newer "tools." These include the Serious Illness Conversation Guide, developed by researchers working with Atul Gawande, found at ariadnelabs.org, and the Vital Talk curriculum, found at vitaltalk.org. Directing the right amount of ACP to the right patient at the right times is an art that can be refined with a guided approach and practice. Dr. Barbara Messinger-Rapport is Chief Medical O§cer — Hospice, for Hospice of the Western Reserve. In partnership with Charles Wellman, MD, Chief Medical O§cer, she plans and oversees hospice and palliative care in the agency's northern Ohio service area. ■ Living Will Form BY BARBARA MESSINGERƒ RAPPORT, MD Comprehensive Advance Care Planning: BEYOND THE 2 0