Advance Care Planning and end-of-life care: A USA perspective

Several recent reports in the USA regarding the use of advance directives (AD) and the value of advance care planning have come to similar conclusions. The standard approach to ADs and programs aimed at prompting ADs as well as the process of advance care planning used in the USA has not achieved its goals. Research results have shown that the prevalence of plans remains low, plans most often are not useful in clinical decision-making, and even when plans do exist, the treating physician is often not aware of the plan. These realities have lead many writers to conclude that ADs have failed and perhaps cannot achieve the intended purpose of both knowing and honoring patient preferences should the patient become unable to make his or her own decisions.

I will argue that what has been learned in the USA is not that advance care planning cannot work, but rather that the standard approach used in the USA has failed. The standard approach to ADs in the USA, has been to create laws that recognize certain types of planning documents, e.g., living wills and power of attorneys for health care, and then to advise adults to fill out these forms. The federal regulation, the Patient Self-Determination Act, actually required hospitals and some other health care organizations to inform patients of these legal documents and to provide basic information about their legal right to have them and how to complete them. While these efforts have resulted in a greater awareness of these planning documents, it has not resulted in any significant change in the prevalence, availability, or utility of advance care plans.

Despite the failure of the promotion of legal, AD documents, these same recent reports conclude that two approaches have shown success. One approach is the Respecting Choices® program and the other is the Physician Orders for Life- Sustaining Treatment paradigm (POLST). These two programs, which are complimentary, have some similar features. They both create a system of planning that standardizes how to plan, how to document plans, how to train health professionals to create and honor plans, and how to make sure that plans are available to health professionals caring for the patient. Both programs also have managed these systems by quality improvement processes and oversight over time.