ADVANCE CARE PLANNING & ADVANCE DIRECTIVES
The idea that patients must choose between quality and quantity of life is an outmoded concept that presents patients with a false choice. Clinicians should discuss with patients that an approach that provides concurrent palliative and disease-focused care is the one most likely to achieve improvements in both quality and quantity of life. Unfortunately, some evidence suggests that end-of-life care for some patients is determined more by local availability of services and physician comfort than by patient wishes. Well-informed, competent adults have a right to refuse life-sustaining interventions, even if this would result in death. In order to promote patient autonomy, clinicians are obligated to inform patients about the risks, benefits, alternatives, and expected outcomes of medical interventions, such as CPR, mechanical ventilation, hospitalization and ICU care, and artificial nutrition and hydration.
Advance directives (ADs) are oral or written statements made by patients when they are competent that project their autonomy into the future. ADs are intended to guide care should patients lose the ability to make and communicate their own decisions. ADs are an important part of advance care planning—defined by an international Delphi panel as "a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The, the goal of which is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness. ADs take effect when the patient can no longer communicate his or her preferences directly. While oral statements about these matters are ethically binding, they are not legally binding in all states. State-specific AD forms are available from a number of sources, including the National Hospice Palliative Care Organization (https://www.caringinfo.org/planning/advance-directives/) and Prepare for Your Care (prepareforyourcare.org). Laws about ADs and advance care planning vary by state in the United States and by country, so it is incumbent upon the clinician to understand the laws in their jurisdiction.
Clinicians should address the core elements of advance care planning for all patients with serious illness—ideally, well before the end of life—to elicit their preferences, to appoint a surrogate, to talk to that person about their preferences, and to complete a formal AD. Most patients with a serious illness have already thought about end-of-life issues, want to discuss them with their clinician, want the clinician to bring up the subject, and feel better for having had the discussion. Patients who have such discussions with their clinicians are more satisfied with their clinician, are perceived by their family as having a better quality of life at the end of life, are less likely to die in the hospital, and are more likely to utilize hospice care. The loved ones of patients who engage in advance care planning discussions are less likely to suffer from depression during bereavement....