The need for safeguards in advance care planning |
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Authors: | Billings J Andrew |
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Institution: | Harvard Medical School Center for Palliative Care, 11 ½ Hilliard Street, Cambridge, MA 02138 USA |
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Abstract: | The recent uproar about Medicare “death panels” draws attention to public and professional concerns that advance care planning
might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy
of a decisionally incapacitated patient when choices about life-sustaining treatments are encountered, but the safety of this
procedure has not received deserved scrutiny. Patients often do not understand their decisions or they may change their mind
without changing their advance care directives. Likewise, concordance between patients’ wishes and the understanding of the
physicians and surrogate decision makers who need to represent these wishes is disappointingly poor. A few recent reports
show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting
patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values,
goals, and preferences. Safeguards for advance care planning should be put in place, such as encouraging physicians to err
on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review non-emergent
patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured
discussion formats that first address values and goals rather than particular life-sustaining procedures. Key targets for
research include: how to improve completion rates for person wanting advance care directives, especially among minorities;
more effective and standardized approaches to advance care planning discussions, including how best to present prognostic
information to patients; methods for training clinicians and others to assist patients in this process; and systems for assuring
that directives are available and up-to-date. |
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