3 tips - You CAN overcome your patient's reluctance to have advance care planning conversationsJan 17, 2022
For physicians, tight schedules, demanding workloads, and lack of training are just a few barriers to starting end-of-life advance care planning conversations with our patients. An even more daunting barrier is our patients’ ambivalence, even reluctance, to have a perceived bad-news conversation. Interestingly, I’ve found that both doctors and patients alike confuse advance care planning conversations with delivering bad-news conversations. In this post, I’ll share three tips to help reduce the stress of end-of-life advance care planning conversations, empower your patients, strengthen physician-patient connections, and improve your medical practice.
3 Tips to Stress-Free End-of-Life Advance Care Planning
As clinicians, we can take comfort. I found most of my patients were pleased when I made the effort to discuss elements of their end-of-life advance care planning in a routine, supportive, and sensitive way. It surprised me to discover that the discussion itself encourages readiness and openness when handled in a supportive and sensitive way.
Tip #1: Encourage patient readiness.
The first step is to encourage patient readiness by asking permission to discuss advanced care planning as a part of routine comprehensive care.
For example, you may notice Mr. Arnold’s concern, and even some alarm, when you request permission to ask him a few questions about the care he would want if he were too ill to speak for himself.
The 67-year-old carpenter asks, “What are you saying, Doc? Why are you asking me that? Is there something wrong?”
You confidently explain this is part of routine comprehensive medical care. As his physician, you can be more effective if you understand what good care might look like for him if such an unfortunate circumstance ever occurred.
You then ask, “Who do you want us to talk to if you can’t speak for yourself?”
He looks puzzled and explains, “No one ever asked me that question before. I need a little time to think about it.”
Yet, he admits to having some thoughts about the subject. The funeral for his next-door neighbor of over thirty years was last week. Jack slipped in his kitchen, struck his head on the ceramic tile floor, and did not survive the serious brain injury. Mr. Arnold thanks you for bringing up this delicate issue, admitting that he didn’t know who to talk to. He had questions, but he didn’t realize how this concerns affected him until now. You thank him, telling him you realize it’s not easy to talk about these things, but it will help you do a better job caring for him.
Tip #2: Choose a significant problem from your patient’s Problem List.
I found it useful to explain current medical and health status to my patients when I framed it as a journey through their life. Is my patient in the early, middle, late, or end stages of their life or chronic illness? Explaining and discussing their medical status in this way helped my patients to imagine prognosis. It helped encourage readiness and confidence. My patients felt better informed.
I begin by selecting a diagnosis from my patient’s Problem List. I review diagnoses and care issues I’m actively addressing and choose the one most likely to be life-limiting, such as cancer or heart failure. Over 50 percent of our patients will ultimately die from aging issues such as frailty or dementia, so if the patient has no life-limiting diagnoses, I use a diagnosis related to musculoskeletal or memory disorders as a segue to begin the conversation.
Using this continuum, or chronic illness trajectory idea, helps your patient visualize where they stand in the present. It also provides a way for your patient to visualize the natural course of this illness over time to the end of their life, to visit their future.
This provides a way to educate your patient about symptoms and physical changes they can expect in future stages so they can tell you how they might adapt to these changes, what their fears and challenges might be, and what assistance and interventions they would need or prefer.
This is the essence of advance care planning. The issue is no longer an abstract one, since you have a way to bring it down to earth.
For example, Mr. Arnold has hypertension-induced heart failure with reduced ejection fraction among the issues on his Problem List. Of those problems, you decide this one is most likely to be life-limiting for him.
You build your advance care planning and patient education plans around this problem. Focusing your planning on one diagnosis helps you manage your time, and Mr. Arnold feels less overwhelmed.
Tip #3: Use Chronic disease action plans to empower your patient.
You can empower your patients with self-management skills, and with the confidence to communicate their needs, values, and preferences.
For example, give Mr. Arnold a brief overview of the heart failure action plan. At each subsequent visit, you choose a single aspect of the plan to review in more detail. This way, Mr. Arnold comes to expect this as part of his routine visit.
He knows to bring his plan to each visit, along with his records of daily symptoms, weights, and blood pressures. You quickly review his understanding of the actions he would take should he experience certain symptoms like weight gain or ankle swelling. You check his understanding of when it’s appropriate to make an emergency visit to your office or the hospital.
You can educate Mr. Arnold about the features of end-stage heart failure and even the dying process. He gets to learn when life-prolonging measures can offer benefit, and when symptom-focused measures (palliative and hospice services) can be more beneficial.
Over several visits, this approach gives you a context to educate Mr. Arnold. He, in turn, can process this information and share his thoughts and preferences with you to document.
Over time, this format of the action plan enables you to learn about his hopes, fears, and confusion about elements of the plan. Mr. Arnold learns to make better, more confident decisions because the action plan helps him learn the skills to do his part and to speak up if there is something he does not understand.
You are giving Mr. Arnold a way to visit his future and prepare for it. He can make better decisions now, in the future, and even in his last months, weeks, and days. You are helping him take responsibility for his health, with the skills and confidence to succeed. T
he action plan gives you a platform for collaborative planning and decision-making. And because Mr. Arnold has better decision-making and self-care skills, he is less likely to choose unnecessary care.
As you can see, these three tips reduce the stress of end-of-life advance care planning to pave the way for conversations that benefit both you and your patients.
You can then reassure your patients that this is not a delivering bad-news conversation and give them information you can use that targets their needs. The action plan lets them tell you what they need. We don’t have to guess or assume.
This approach also provides a foundation for shared decision-making. It empowers our patients to make better decisions. It helps you deliver effective care with less waste.. Ultimately, this approach increases our chances of delivering care that truly matters.
Until next time.
Forrest Jones MD
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