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Episode 2: Advance Care Planning and Advance Directives

There is often confusion about the various advance care planning forms available, including advance directives, Do Not Resuscitate (DNR) forms and Physician Orders for Life Sustaining Treatment (POLST) forms. In this episode of The Talk, family physicians discuss the differences between these documents and how they can help patients understand and complete them, as well as contemplate and make clear their medical wishes in advance of a terminal diagnosis or health care crisis.


Some confusion – on the part of both patients and physicians – may stem from a lack of clarity about what, exactly, patients are deciding about, as well as our overall discomfort with thinking about our mortality. As Peter Regan, the national medical director of Compassion and Choices, notes, “There is a taboo about talking about death.”


Advance care planning forms outline possible health care scenarios and interventions including serious illness, paralysis, intravenous feeding, ventilators, CPR and resuscitation. Incorporating advance care planning into family medicine, especially early on, can educate patients about these specific circumstances and choices, as well as help them identify their values and goals.


Lisa Thomsen, a family physician in a solo practice in northwest Los Angeles, brings up advance care planning at least once a year at “the annual,” in addition to reviewing vaccines, medications and screening tests. She says, “part of that going over everything conversation is also, ‘oh, and what are your end-of-life concerns? Do you have any? Do you have any plans? Do you have an advance directive?’”


Given the often tight schedules of busy family physicians, it can be difficult to fit advance care planning into a routine visit, but Medicare now includes two new codes for these conversations: CPT Codes 99497 and 99498. Physicians agree that it is important to have these conversations early on and often as a patient’s wishes may change over time. A younger patient, for example, may want all measures and interventions to be taken to prolong life but, as they age, may adjust those wishes.


Patients often have misunderstandings about CPR and life-sustaining interventions, in part due to portrayals on television. Palliative care physician Gregg VandeKieft observes, “there have been studies…of the frequency of successful resuscitation in televised medical dramas compared to real life, and let’s just say television doctors have a much higher success rate.” Educational videos about the realities of CPR and other interventions may help patients better understand their choices.


Various circumstances and types of life-sustaining treatment are outlined in the POLST form – an often brightly colored form commonly filled out when patients have a terminal diagnosis or live in an extended care or senior facility. Palliative care specialist Lowell Kleinman uses the “surprise question” to determine whether a patient should have a POLST form. He asks, “would you be surprised if your patient passed away in the next 12 months?’”


Family doctor Clarissa Kripke likes to have POLST forms for her patients with complex disabilities as “some people may be surprised to know that people can live good lives on ventilators at home…there are many people with disabilities…who live well on chronic ventilators.”


One of the common points of confusion on the POLST form is the difference between the various sections, including the distinction between what happens if, as outlined in section A, a patient is found without a pulse versus section B - if they experience a serious and sudden illness. Family physicians can review the form with patients and clear up any confusion.


In addition to medical wishes, it is important to discuss health care proxies with patients so they can designate someone they trust and who understands their wishes. Not only do advance care planning forms help patients get the treatment they want at the end of life, but they can also give the gift of clarity to family members about how to proceed when their loved one faces serious illness and can no longer communicate.


As preparation for having compassionate advance care planning conversations with patients, it can be helpful for family physicians to complete their own advance care planning forms and contemplate their priorities and wishes for end of life.


For more information on advance care planning, CAFP recommends the following resources: