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Advance Directives: Improving Patient Care at End-of-Life

By Rhea Go-Coloma

hospice palliativeMary, 89, who has a history of heart failure and spinal stenosis, lives at home with her elderly husband. Over the past few months, she’s been admitted twice to the hospital with symptoms of heart failure. Her Medicare Advantage plan used a predictive algorithm to identify Mary as a candidate for home-based palliative care. When seen at home on the first visit, the palliative nurse discussed with her specific goals of care.

Mary’s preference was to avoid aggressive care and hospitalization, and to disable her implantable cardioverter defibrillator — decisions that were spelled out in an advance directive (AD) — legal documents that instruct physicians on how to carry out medical decisions, especially when an individual with advanced illness is unable to communicate during a medical crisis. This includes Durable Power of Attorney for Healthcare, a Living Will, and a form confirming the Physician Orders for Life-Sustaining Treatment.

ADs represent the best way for individuals to ensure that their wishes for end-of-life care will be carried out. Unfortunately, only 25 percent of Americans have recorded their end-of-life medical wishes in a legal document. This presents a growing problem because more than half of patients are unable to participate in end-of-life decisions when the time comes.

Advance Care Planning

The best approach to exploring end-of-life goals of care with patients is through advance care planning. This involves multiple steps designed to help individuals a) learn about the healthcare options that are available for end-of-life care, b) determine which types of care best fit their personal wishes, and c) share their wishes with family, friends and their physicians.

In some cases, patients who have already considered their options may need only one advance care planning conversation with their physician. That said, quite often individuals require a series of conversations with their physician or other health professionals to clearly understand and define their end-of-life wishes.

Because many physicians and other healthcare professionals may feel uncomfortable discussing the progression of an individual’s condition, it can be helpful to involve end-of-life care experts to facilitate clear communication.

Partnering with Palliative Experts

One advanced care model, which is offered by Turn-Key Health, uses specially trained and equipped nurses and social workers who interact and coordinate care with the designated physicians or other professionals who are responsible for the person’s ongoing medical care.

Known as community-based Palliative Extensivists™ (PEs), these nurses and clinical social workers provide education, training and resources to help individuals with advanced illnesses and their family caregivers. These services span pain and symptom management, medication reconciliation, care coordination, goals of care discussions and advance care planning, which includes completing ADs.

This more personalized, high-touch approach to care in the community offers communication, guidance on advanced care planning and ADs, and enhanced psychological and physical comfort at a time when individuals with serious illnesses need it the most.

Rhea Go-Coloma, LMSW, is Chief Administrative Officer, Hospice of the West

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