Advance care planning and assisted living residents
Wayne McCormick, MD, MPH
We plan for all sorts of things—vacations, weddings, moving, retirement. Name it and someone likely is out there planning for it. We are encouraged to have a disaster plan for our family and asked for an emergency contact when we book a flight. One thing that we are loathe to plan for, however, is how we want to be cared for if we are unable to care for ourselves. Having these discussions should be a part of the fabric of our lives—yet, despite progress, they typically are not. That's why we believe that the recent recognition of the importance of Advance Care Planning (ACP) for Medicare beneficiaries goes a long way toward remedying such concerns. For older adults, many of whom live in assisted living communities, these conversations are all the more important.
ACP is a voluntary, comprehensive, ongoing, person-centered approach to communication about future healthcare choices. It's intended to help people reflect on goals, values, and beliefs; consider future preferences for medical treatment; identify a surrogate or proxy decision-maker; and document these decisions in a way that makes future care more manageable and responsive to personal needs and preferences. In geriatrics, but also across medicine writ large, ACP is becoming a standard of care as consensus mounts regarding its value, impact, and importance.
- ACP increases the likelihood that people's wishes are clearly understood and respected.1 In a prospective randomized clinical trial of a coordinated approach to ACP in Australia, for example, family members of nearly 90% of participants who received ACP services reported that their loved one's end-of-life wishes were known and followed.1 In contrast, for the control group that had no official outlet for making care preferences known, only 30% of family member respondents reported that end-of-life care decisions were recognized.1
- ACP leads to fewer hospitalizations, less intensive treatments, and an increased likelihood that people will spend their finals days in a setting they choose rather than in an environment they'd ultimately prefer to avoid.1,2,3 In a study of more than 1,500 older adults, those who had documented their end-of-life care preferences with an advanced directive were the most likely to die at home with hospice or in a nursing facility rather than in a hospital.2 They were also less likely to have a feeding tube or a respirator in the last month of life, which speaks to the value of formalizing wishes before someone reaches decisional incapacity (particularly when intubation may be a cause for concern).2
- ACP contributes to higher satisfaction with the quality of care received, as well as less stress, anxiety, and depression among caregivers and surviving relatives.1,3 One study involving family members of people with documented end-of-life care wishes found that these family members reported fewer concerns with health professional communication and a greater sense of knowing what to expect from the end-of-life care process.2 And another recent randomized trial also suggested that people receiving palliative care as part of their health management plan survived for significantly longer than people receiving usual care on its own.4
As professionals involved in initiating these complex, vitally important conversations with older adults, members of the American Geriatrics Society (AGS)—more than 6,000 geriatricians, geriatric nurses, social workers, family practitioners, physician assistants, pharmacists, and internists with particular expertise in eldercare—know that ACP services are about more than “best practices” or standards to increase clinical efficiency; they define the very heart of high-quality care. The understanding and clarity ACP promotes is an invaluable connector linking people to expert medical advice, and expert medical advice to personal values and beliefs, by extension. At Bailey-Boushay House, a care community for older adults living with HIV/AIDS where Dr. McCormick serves as Medical Director, this is something we see manifest in frank conversations about a disease that is increasingly seen as chronic, but that comes with unique challenges and changes that may raise more questions than answers where end-of-life care is concerned. And for a caregiver like Nancy, ACP is as much about acknowledging personal care preferences as it is about ensuring she feels empowered to do what's best—and what's desired and important—for an older loved one who has put faith in her as a decision.
Earlier this year, the AGS and 65 other organizations representing consumers, health professionals, caregivers, faith-based healthcare systems, and a cadre of other advocates joined together in urging the Centers for Medicare and Medicaid Services to include payment for voluntary ACP in the Physician Fee Schedule for 2016. We're thrilled that the recently released proposed rule reflects our recommendation. Like geriatrics health professionals who often care for older adults in assisted living facilities, the CMS is standing behind the importance of a key service for Medicare beneficiaries that can make planning for the future just a little less intimidating. In clearly defining where we are, where we're going, and how we want to get there, ACP can do much to shrink unchartered territory and make the map toward what matters most adaptable to the road ahead.
Wayne C. McCormick, MD, MPH, is immediate past president of the AGS; professor of medicine at the University of Washington, Department of Medicine, Division of Gerontology and Geriatric Medicine, Harborview Medical Center; and medical director of Bailey-Boushay House. Nancy E. Lundebjerg, MPA, is the CEO of the AGS.
1 Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ. 2010; 340: C1345.
2 Teno JM, Gruneir A, Nanda A, Wetle T. Association between advance directives and quality of end-of-life care: A national study. J Am Geriatr Soc. 2007; 55(2): 189-194.
3 Molloy DW, Guyatt GH, Russo R, et al. Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. JAMA. 2000; 283(11): 1437-1444.
4 Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM. 2010; 363(8): 733-742.