Advance care planning: It is time to rethink our goals

• DOI: 10.1111/jgs.18511
• Publication Date: 2023-07-31T12:13:50Z
• Authors: Chetna Malhotra
• Keywords: Advance Care Planning

What is the purpose of advance care planning (ACP)? Does it facilitate goal concordant care,1, 2 improve other patient and caregiver outcomes or curtail escalating healthcare costs at end life (EOL)? In short, worth time resources spent? These are questions that have plagued researchers, clinicians, policymakers internationally,3 thus challenging increasing efforts to implement promote uptake ACP conversations its use as a metric measure quality EOL care. Recent systematic reviews shed some light on this issue.4, 5 report large number trials conducted among seriously ill but not imminently dying patients failed show improves goal-concordant EOL.5 Further, demonstrate impact improving life. There also inconsistent evidence patients' mental health, reduces health costs, increases home deaths. Thus, does seem change trajectory they receive A plethora literature has focused gaps challenges in implementation ACP. include, may be limited to, lack appropriate legislative framework, physician training involvement, accessibility documents medical records.4, 6-8 However, even if endless resources—time, money, manpower—are spent addressing all documented facing implementation, programs still able achieve holy grail The reason for lies within realms cognitive psychology. When making decisions future, we project our current preferences onto when there likely an incongruity between future experiences preferences. This phenomenon termed projection bias.9 Relatedly, people certain affective states, such distress pain, difficulties appreciating what their will these states. known hot–cold empathy gap.9 several examples bias literature. Chochinov et al. interviewed 168 cancer patients, admitted palliative unit, frequent intervals assess live. They found live fluctuated with levels dyspnea distress, indicating physicians' clinical should based momentary assessment live.10 prospective cohort advanced heart failure, surveyed every 4 months over years, preferred type (aggressive vs. non-aggressive) place death was reported time.11, 12 Interestingly, consistent one direction influenced by prognostic beliefs eliciting Similar results were studies cancer,13 study caregivers dementia. summary, caregivers' goals changes circumstances beliefs. mean process decision-making? While feasible align preferences, face ever-changing challenging. words, transient, then achievable aim programs. however promise. First, many do understand enough about illness due patient–physician communication,9 condition prognosis evolve. clearly disclosed refuse acknowledge it.14, 15 Their can symptoms, two unrelated. indicates dissonance patients.16, 17 potential educate (patients') illnesses. happen continually address evolving conditions, prognosis, dissonance. Second, allows clarify, express share important them providers surrogates, paving way engage shared decision-making providing opportunity make care.18 again suggests need revisited again. Third, though actual specific scenarios point time, prepare caregivers, those in-the-moment decisions.19, 20 Thus "preparation" rather than "planning" objective ACP.5 For providers, implies documentation situation hypothetical scenario. Documented considered only expressed same under variety scenarios, settings. indicators success redefined ACP? As mentioned earlier, unlikely including care, life, reduce substantial way. I, therefore, recommend ACP's measured context three objectives (Figure 1). education assessed measuring understanding prognosis. value-elicitation extent which values/goals whether caregivers/surrogates values, strengthens patient–provider patient–caregiver relationships, participate actively decision-making, treatments values goals. Whether prepares asking feel prepared decisions, bereavement adjustment. provision physical health. Therefore, approach document useful, unless done patients. new required. approach, main objectives—(1) education, (2) elicitation guide (3) preparation decisions. relation objectives. It rethink define success. "It success" Chetna Malhotra conceptualized drafted article. author declares no conflicts interest. None. We thank Dr. her thoughtful thought-provoking Commentary Advance Care Planning (ACP) Directives (AD). One got me interested career Geriatric Medicine I resident seeing very frail older who obviously come Emergency Department Intensive Unit full code status. wondered why futile, uncomfortable, expensive being done. By necessity learned could AD, since my experience increased exponentially. disagree Malhotra's thoughts recommendations, own complimentary. you ever witnessed 90-pound, 90-year-old woman bedridden unable recognize communicate loved ones, getting CPR nursing home, know how brutal futile is. Numerous ribs cracking virtually chance meaningful survival. People must educated choices it. had families ask years: "What think JO?" Many physicians say something effect: "it your decision," thereby abrogating responsibility helpful extremely stressful time. My respect ethical tenet paternalism, tell would parents (now actually did parents). help relieve family surrogates from stress lifetime guilt "pulling plug." am skeptical order forms POLST. convinced without background previous sign truly risks benefits treatment options. addition, depending circumstances. example, elected antibiotic develop painful abscess cellulitis requires comfort. tend favor more general directives simply states expectancy, want any intervention cause discomfort benefit. With directive, professional best interest JAGS readers thoughts, encourage submit review publication Letter. -Joseph G. Ouslander, MD