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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Site Index
    Back to Module 1: Advance Care Planning
    Why is Advance Care Planning Important?

    Benefits and Importance of Advance Care Planning
    The Physician's Involvement in Advance Care Planning

    Avoiding Common Pitfalls in Advance Care Planning

    Benefits and Importance of Advance Care Planning

    • Builds trust and teamwork between patient, physician, and proxy
    • Uncertainty, anxiety reduced
    • Avoids future confusion and conflict
    • Permits peace of mind for patient and proxy

    The Physician's Involvement in Advance Care Planning

    Why Does the Physician Need to be Involved?

    • To initiate and guide the advance care planning process
    • To understand the patient and establish a trustworthy shared decision-making process
    • To feel comfortable that he or she can pursue the goals and priorities for care that the patient wants

    Overcoming Barriers to Involvement

    • Common physician concerns about advance care planning:
      • "It's too idealistic"
      • "It's too time-intensive"
      • "My practice is too busy to accommodate it"
    • Within the proper framework, advance care planning can be incorporated into practice in a routine and practical way:
      • The patient, proxy, and family can do most of the work without the physician if they are given a worksheet and background materials

    Involving Other Team Members

    • Some physicians choose to have other members of the health care team assist them with advance care planning (e.g., a nurse, physician assistant, or social worker)
    • Once the patient’s ideas have been gathered, the physician can focus on the core discussions in direct meetings with the patient, proxy, and family
    • Preparatory work will permit these discussions to be to the point and effective
    • Once the core discussion has taken place, invite the patient to reflect on things and then return at a subsequent visit with decisions to review

    Avoiding Common Pitfalls Advance Care Planning

    Anticipating and avoiding the common pitfalls is essential to a successful advance care planning process. This section contains guidelines for how to avoid the following common pitfalls:

    Failure to Plan

    • Do not avoid advance care planning
    • Be pro-active
    • It is easy to forget the central role of the patient, and easy to forget the importance of the proxy. Involve both early and often

    Proxy Absent for Discussions
    • Do not leave the proxy decision-maker(s) out of the initial discussions with the patient

    Unclear Patient Preferences

    • Vague statements can be dangerously misleading
    • Be sure to clarify patient preferences if they do not seem clear to you or to the proxy
    • For instance, patients who make statements such as "I never want to be kept alive on a machine" should be asked to clarify whether their wishes would change if their condition were readily reversible, or if their prognosis were unclear

    Discussion Focused Too Narrowly
    • Avoid isolated do-not-resuscitate (DNR) discussions
      • Such discussions often create chaotic emotions and thoughts in patients who have to imagine imminent death to make the decision
    • A DNR discussion is usually an indication that other palliative goals and measures should be considered in the context of a range of scenarios

    Communicative Patients Are Ignored
    • Sometimes people assume that what a patient wants in the present is what he or she indicated for future possible scenarios
    • As long as the patient is competent, talk to him or her
    • An impaired patient may still be able to express wishes at some level. In such cases, it is essential to take into account
      • BOTH the advance directive
      • AND any tangible evidence of the patient’s current wishes

    Not Reading the Advance Directive

    • Always read advance directives
    • Do not assume that you know what is stated in an advance directive
    • Remember that advance directives can be for aggressive intervention, comfort care, or a wide range of specific views and must be read and understood
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