Respecting Choices Advance Care Planning
Stages of Planning
One of the greatest misconceptions about advance care planning (ACP) is that it is a static process, a one-time event. Attempting to plan for all possibilities in a single document or at a single point in time is both impossible and unnecessary.
At Respecting Choices, we know that effective ACP is a process of communication that helps individuals
- understand their choices for future healthcare
- reflect on personal goals, values, religious, or cultural beliefs
- talk to physicians, healthcare agents, and other loved ones as needed.
To be effective, this process of communication needs to be individualized, based on a person’s state of health, and revisited at appropriate times. The “stages of planning” have three distinct and focused “steps.”
First Steps® ACP is appropriate for all adults, but should be initiated as a component of routine healthcare for those over the age of 55-65. The goals of this stage of planning are to motivate individuals to learn more about the importance of ACP, select a healthcare decision maker, and complete a basic written advance directive. This First Steps advance directive should identify basic goals for life-sustaining treatment if the person should suffer a severe, neurologic illness and is unlikely to recover.
First Steps ACP typically begins in two ways:
- as part of routine annual physical examinations by primary healthcare providers (e.g., physician, nurse, patient representative)
- by community leaders (e.g., clergy, advocates for seniors, parish nurses) who become trained as ACP facilitators to offer this service within the community-at-large
First Steps ACP is the basic foundation for weaving ACP discussions into the routine of good patient care and preventative healthcare for all adults. When integrated in the outpatient or community setting and early in the course of healthcare, First Steps discussions help to normalize the concept of planning, and orient individuals to the importance of regular review and update of written plans.
Next Steps ACP should be initiated for patients with chronic, progressive illness who have begun to experience
- a decline in functional status
- co-morbidities (additional illnesses)
- more frequent hospitalizations
- at risk for complications that would leave them unable to make their own healthcare decisions.
The goals of this stage of planning are to assist patients in understanding a) the progression of their illness, b) potential complications, and c) specific life-sustaining treatments that may be required if their illness progresses. Understanding life-sustaining treatments includes each treatment’s benefits, burdens, and alternatives. Additionally, the individual’s healthcare agent(s) and other loved ones are involved in the planning process to become more prepared to make substituted decisions if necessary, and support the plan of care developed. In this stage of planning, a more specific written plan is developed that identifies goals of care when death or cognitive and/or functional impairments are likely. The Next Steps conversation is initiated as a component of chronic disease management and delivered by trained professional facilitators who have experience with illness trajectories and related patient care.
Last Steps™ ACP is intended for frail elders or others whose death in the next 12 months would not be surprising. Many of these individuals are living in long-term care facilities, are at risk of complications, and at risk of losing their decision-making capacity. Specific and timely life-sustaining treatment decisions must be made and converted to medical orders that will guide the actions of healthcare providers and be consistent with the goals of the individual. Last Steps ACP discussions are focused on assisting the individual, or the designated healthcare agent(s), in making the following healthcare decisions: 1) CPR; 2) goals of care for cardiopulmonary failure, including hospitalization; 3) artificial nutrition and hydration; and 4) comfort care options. A specific written plan must be created to document these decisions and ensure they are honored by healthcare providers throughout the continuum of care. The Physician Orders for Life-sustaining Treatment (POLST) paradigm is proven to be the most effective system to accomplish this goal.
Find out about the education Respecting Choices offers to support the staged approach to advance care planning.
