Abstract
Advance care planning (ACP) is the process of clarifying and documenting the future health-care wishes of a patient who has capacity to participate in medical decision-making. As older adults are at particular risk of losing decision-making capacity due to health issues, discussing wishes for future care can help family members and health-care providers respect a patient’s preferences even when they are unable to communicate. This chapter outlines how to approach and document advance care planning discussions, including preferences for cardiopulmonary resuscitation, mechanical ventilation, and care at the end of life. Selection of a proxy decision-maker and legal documentation are addressed. Completion of Physician Orders for Life-Sustaining Treatment (POLST) is also discussed.
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Back A, et al. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. Cambridge: Cambridge University Press; 2009.
Baile WF, et al. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–11.
Bernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003.
Bisson JI, et al. Developing a care pathway for advance decisions and powers of attorney: qualitative study. Br J Psychiatry. 2009;194(1):55–61.
Detering KM, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
Ehlenbach WJ, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22–31.
Elpern EH, et al. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care. 2005;14(6):523–30.
Hammes BJ, et al. A comparative, retrospective, observational study of the prevalence, availability, and specificity of advance care plans in a county that implemented an advance care planning microsystem. J Am Geriatr Soc. 2010;58(7):1249–55.
Heyland DK, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778–87.
Lum HD, et al. Teaching medical students about “the conversation” an interactive value-based advance care planning session. Am J Hosp Palliat Care. 2017;35(2):324–9.
Portanova J, et al. It isn’t like this on TV: revisiting CPR survival rates depicted on popular TV shows. Resuscitation. 2015;96:148–50.
Sudore RL, et al. A novel website to prepare diverse older adults for decision making and advance care planning: a pilot study. J Pain Symptom Manag. 2014;47(4):674–86.
Sudore RL, et al. Uncertainty about advance care planning treatment preferences among diverse older adults. J Health Commun. 2010;15(S2):159–71.
Swidler RN. The family health care decisions act: a summary of key provisions, 15 NY St. BA. Health LJ. 2010;32:33.
Teno J, et al. Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. J Am Geriatr Soc. 1997;45(4):500–7.
Teno JM, et al. Association between advance directives and quality of end-of-life care: a national study. J Am Geriatr Soc. 2007;55(2):189–94.
Tierney WM, et al. The effect of discussions about advance directives on patients' satisfaction with primary care. J Gen Intern Med. 2001;16(1):32–40.
Wynn S. Decisions by surrogates: an overview of surrogate consent laws in the United States. Bifocal. 2014;36(1)
Yadav KN, et al. Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Aff. 2017;36(7):1244–51.
Yung VY, et al. Documentation of advance care planning for community-dwelling elders. J Palliat Med. 2010;13(7):861–7.
Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. New Eng J Med. 2010;362(13):1211–8.
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Biewald, M.A. (2020). Advance Care Planning for Older Adults. In: Chun, A. (eds) Geriatric Practice. Springer, Cham. https://doi.org/10.1007/978-3-030-19625-7_29
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DOI: https://doi.org/10.1007/978-3-030-19625-7_29
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