Skip to main content

Trying to Integrate Advance Care Planning Into Clinic


As a geriatrician who primarily sees patients in clinic, I find myself often wondering how best to apply what I’ve learned on the inpatient Palliative Care service to my outpatient setting. Addressing advance care planning sounds so sensible, yet somehow it often ends up being much more challenging than expected.

The other day in my outpatient geriatrics clinic, I addressed advance care planning with two different patients. One ended up being easy, the other…not so easy. In both cases I had already brought up advance care planning during the previous visit. (Although the policy wonks seem to think that just one paid visit every 5 years can do the trick.)

The easy situation was completing a POLST (Physician Orders for Life-Sustaining Care) for Mr. T, a 94-year old man with moderate dementia. As usual, Mr. T came to his visit accompanied by his son John*, who is his DPOA and used to be the primary daily caregiver as well (Mr. T eventually was placed in a board & care). Although in previous visits both the patient and his son had confirmed Mr. T’s preference to be DNR and allowed to die when his time comes, now that we were signing a POLST, I asked Mr. T again what he would want people to do if he were found down without a heartbeat.

“I’d want ‘em to get the shovel!” he said, cackling. His son chuckled as well. “Oh, Dad,” he said as he patted his father’s shoulder fondly. Together, we completed the POLST, indicating that Mr. T should be allowed a natural death, yet wants to be transferred to the hospital for treatable illnesses. Easy, but it all did take 25 minutes.

The next patient was Mr. N, accompanied as always by his partner & DPOA, Tom. Mr. N, who has Parkinson’s, is only 80, but over the past year has developed some definite cognitive impairment; his physical condition remains otherwise good. His partner, who has struggled with the caregiving, had recently left me a voicemail saying he was looking into hospice but hadn’t yet brought this up with his spouse.

As I was saying, not so easy. I tried to start off by eliciting Mr. N’s understanding of his condition and trajectory. It was hard to hear him well, since he speaks slowly and haltingly. He told me that he has Parkinson’s but thought things were going pretty well, and thought that the new medicine will make him better.

Hmm. I had hoped he’d have more insight and memory. We had discussed Mr. N’s declining cognitive abilities and diminishing function in several previous visits. And no new medicine had recently been started. What to do? How does one engage in advance care planning when: a) patient, proxy, and doctor have different visions of reality; b) you think perhaps the patient doesn’t have capacity but you’re not 100% sure; c) it takes a long time for patient to speak clearly; d) you’re now running 10 minutes late for the next appointment; and e) you have no slots available in clinic next week (this is hardly the kind of thing that can be addressed during an overbook)?

The truth is that in clinic somehow I muddle through these situations, as best I can. I believe in advance care planning, in understanding goals, and in helping people figure out what is the right care for them, given their values and medical condition. But often, it seems so much harder than doing inpatient palliative care consults.

*Names and certain details have been changed to protect identities.

Comments

Dan Matlock said…
Agree 100%. Inpatient palliative care is much more satisfying than outpatient clinic. That said, these outpatient discussions are of paramount importance.

Perhaps someday folks will recognize the value of good primary care...
Anonymous said…
I really appreciated this post - the situation you describe is real, and not well addressed in the propaganda, sorry, teaching about advance care planning. Where I work, geriatricians are piloting a referral clinic whose "intervention" will consist of 3 planned outpatient visits for facilitated advance care planning. With the second patient you describe, sometimes just promoting reflection by the family caregivers, as you do, is a start to the process of being prepare, cognitively & emotionally, for future decisions - the "social function" of advance care planning. Practically, specifically training SW or RN's to have these conversations may be helpful. Paul McIntyre
Bree Johnston said…
Thank you, Leslie.

It is really telling that the "easy" discussion took 25 minutes. It has been said before and more eloquently than this, but until we get adequate time to do what we need to do in primary care (and reimbursed for it), primary care will have a difficult time recruiting.

These discussions, challenging as they are, are incredibly valuable to patients. Leslie, I hope that you feel that the work you are doing is incredibly important - because it is.

We need to fight to get recognition for this type of work (via adequate time and $$ on a societal level). Until then, we need to support each other for our contributions.

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Opening the Black Box of LTACs: Podcast with Anil Makam

What happens in Long Term Acute Care Hospitals, or LTACs (pronounced L-tacs)?  I've never been in one.  I've sent patients to them - usually patients with long ICU stays, chronically critically ill, with a gastric feeding tube and a trach for ventilator support.  For those patients, the goals (usually as articulated by the family) are based on a hope for recovery of function and a return home.

And yet we learn some surprising things from Anil Makam, Assistant Professor of Medicine at UCSF.  In his JAGS study of about 14,000 patients admitted to LTACHs, the average patient spent two thirds of his or her remaining life in an institutional settings (including hospitals, LTACs and skilled nursing facilities).  One third died in an LTAC, never returning home.

So you would think with this population of older people with serious illness and a shorter prognosis than many cancers, we would have robust geriatrics and palliative care in LTACs?  Right? Wrong.

3% were seen by a geriatrici…

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…