Advance Care Planning

Honoring Choices Minnesota envisions a three-part process to help ensure that a patient’s wishes are honored at end-of-life: Advance care planning: facilitated conversation between a patient and their health care agent Advance directive: patient directed document outlining care preferences POLST: physician’s orders used to translate patient’s wishes into specific actions for treatment

Getting patients ready to have “The Talk”

With the US population aging, increasing rates of chronic disease, and never knowing when you might get hit by a bus, patients need to have “The Talk” about their end-of-life wishes with their physicians and families.

The Agency for Healthcare Research and Quality has documented the need for more effective advance care planning, from the need for documents that require less interpretation to physicians being unaware that patients had health care directives.

According to a Harvard Medical School study, nearly half of patients with metastasized lung cancer and their doctors did not discuss hospice care within four to seven months of their diagnosis.

Some physicians do not want patients to think that they are not going to survive, even if the reality is that a patient with metastasized lung cancer is not expected to live more than two years. Delaying discussions about end-of-life preferences can increase the difficulty of the discussion as conditions become more critical.

Many primary care physicians facilitate advance care planning with their patients. State support of Health Care Homes in Minnesota should foster increased planning. And, advance care planning is growing in the Twin Cites in part because of Honoring Choices Minnesota, a metro-wide community approach to fostering increased use of advance care planning. Honoring Choices is supported by the East Metro Medical Society and the West Metro Medical Society.

Some Minnesota health care systems are working to formalize systems for initiating advance care planning discussions with aging and palliative care patients. Advance directive discussions are thoughtful and deliberate. They help people examine their values, beliefs, and desires to assist them in making the choices that are right for them at end of life and to ensure those choices are documented. A University of Pennsylvania School of Medicine study found that people who did not have written directives were twice as likely to change their preferences than those who did. Those who had directives were more likely to maintain consistent wishes for end of life.

Care preferences, culture, equity

A recent University of Pittsburgh study showed that when people with Medicare were asked about their treatment preferences if diagnosed with a terminal illness, the majority did not prefer life-prolonging measures.

However, the study found a correlation between end-of-life care preferences and race. African Americans and Hispanics were both more likely to opt for intensive end-of-life care. African Americans were twice as likely as whites to say they would want life-prolonging treatments.

Theories for this difference include: belief that the health care system is racially biased, communication barriers, and lack of a regular doctor, which makes end-of-life discussions more difficult within the limited patient-physician relationship.

The likelihood of a patient-physician discussion about hospice varied with race and ethnicity, according to a Harvard study. Hispanics (43%) and African Americans (49%) were less likely to have discussions than whites (53%) and Asians (59%).

Having a standard of care for physicians to offer patients advance care planning, as they would offer a screening for colorectal cancer, might help decrease disparities in care and increase patient confidence that their wishes will be adhered to.
HealthEast is trying a Hmong facilitator for the planning process, as part of its efforts to ensure that culturally responsive components are built into its pilot programs like Honoring Choices Minnesota.

Elizabeth Anderson, HealthEast director of cross cultural services, was surprised when an elderly Hmong man chose to be an organ donor, as Hmong typically do not donate organs at death. He said, “My philosophy is different. I believe it is the right thing to do.” Then added, “Let’s be sure to get this in writing because my family will object.” Anderson said the key is not to assume that a specific patient has the beliefs generally held by the overall culture.

In support of advance directives

Stratis Health’s quality efforts have long encompassed chronic disease and end-of-life care. As we work with communities to build capacity for palliative care, we’re sharing resources on advance care planning. And, following the hype about “death panels,” our Human Resources staff planned a lunch-and-learn so staff can determine if they are ready to have “The Talk.”