The Journal of the Arkansas Medical Society Issue 12 Vol 114 | Page 13

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C L O S E R
to help your patient make an
informed choice about health care.
Some providers ask:
“Tell me what you understand about
your current health or [specific
condition or illness…i.e. COPD, lung
cancer, dementia, heart failure,
etc.]? What does your [spouse,
surrogate(s), family] know about
your health?”
• If you identify gaps between
what your patient and surrogate
know and what you think they
should know, you will need to
provide clarifying information. This
should include facts about their
condition/prognosis and examples
of decisions about treatment(s)
or procedure(s) they, or their
surrogate, may face in the future.
You might say:
• “I know this is difficult to
imagine, but your dementia
may affect your ability to eat
enough to stay alive. If this
happened, would you want to
be fed with a feeding tube?”
• “This can be hard to think
about, but if your [specific
condition or illness] were to
worsen and your heart stopped
… would you want someone
to try and bring you back?”
• If your patients indicate they
would want these treatment(s)
or procedure(s), acknowledge
and document preferences
in their medical record and
encourage them to do so in their
AD. However, do not stop there. It
is very important to keep asking
questions to learn whether there
may be circumstances that would
affect their preferences. For
patients who prefer life support,
ask how long they would want the
support to last and what criteria
L O O K
AT
Q U A L I T Y
A CLOSER LOOK AT QUALITY
should be used by their surrogate
decision maker(s) and health care
providers to decide when to stop.
“I will document in your record that
you want [specific procedure…i.e.
feeding tube, CPR, etc.]. However, I’d
also like to talk about whether there
are any circumstances when you
wouldn’t want [specific procedure]
to be done? Would you want to
try these treatments for a limited
period? If so, how long?”
By communicating
their preferences and
documenting them in an AD
[advance directive], your
patients are being given a
voice in their health care
and have a greater chance
of ensuring care is aligned
with their goals and values.
By communicating their
preferences and documenting them
in an AD, your patients are being
given a voice in their health care and
have a greater chance of ensuring
care is aligned with their goals
and values. It is very important to
encourage your patients to provide
a copy of their AD to you and, their
surrogate(s) and family members.
Also, provide a copy to any medical
center where your patient anticipates
being admitted for care. Your patients
should regularly be reminded to
revise their plan if relationships
or health status change. An AD
can be revoked with a simple oral
declaration. If the AD is revoked, be
sure the documents are removed or
rescinded and any new documents
are added to the medical record.
As a health care provider, you have
seen what can happen when patients
don’t prepare for these challenging
decisions. Reflect on how having a
plan, or a lack of one, had an impact
on the “in-the-moment decisions”
for your patient. How did it affect
their family and others involved in
their care? Your proactive actions to
encourage patients to plan ahead can
relieve stress, anxiety and depression
for their surrogate(s) and family
during a very difficult time. This
planning is an essential component of
providing patient-centered and goal-
concordant care. 5 s
Dr. Garner is a dual-boarded physician
in geriatrics, hospice and palliative care,
and she and Ms. Jensen work at the
Veteran Affairs Health Care System in
North Little Rock.
REFERENCES
1. Messinger-Rapport BJ, Baum EE, Smith
ML. Advance care planning: Beyond
the living will. Cleve Clin J Med 2009;
76:276.
2. Hickman SE, Hammes BJ, Moss AH,
Tolle SW. Hope for the future: achieving
the original intent of advance
directives. Hastings Cent Rep 2005;
Spec No: S26.
3. Yadav KN, Gabler NB, Cooney E, et al.
Approximately One In Three US Adults
Completes Any Type Of Advance
Directive For End-Of-Life Care. Health
Aff (Millwood) 2017; 36:1244.
4. BMJ-British Medical Journal. "Advance
care planning improves end of life
care and reduces stress for relatives."
ScienceDaily. ScienceDaily, 23 March
2010.
5. Sanders JJ, Curtis JR, Tulsky JA.
Achieving Goal-Concordant Care:
A Conceptual Model and Approach
to Measuring Serious Illness
Communication and Its Impact. J Palliat
Med. 2018 Mar;21(S2):S17-S27. doi:
10.1089/jpm.2017.0459.
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