The Common Sense Guide to Improving Palliative Care > Advance Care Planning > 3.9 Communication Strategies to Initiate Advance Care Planning

Sick To Death book cover This extract from the online edition of The Common Sense Guide to Improving Palliative Care is used with permission.

Advance Care Planning: Communication Strategies to Initiate Advance Care Planning

The following table summarizes some useful communication strategies to initiate Advance Care Planning (ACP) depending on the health status of the person you are talking with.

Table 3.1

With healthy people
Content of DiscussionsAction ItemsSuggested Communication Strategy
  • Identification and notification of surrogate/proxy decision-maker.
  • Identification of preferences about undesirable outcome states (e.g., persistent vegetative state).
  • Note atypical beliefs or preferences (e.g., Jehovah's Witness).
  • May complete durable power of attorney.
  • Discuss proxy appointment and values with surrogate.
  • Write down preferences.
  • "There are many drugs that we can use to treat your hypertension; one is less expensive, but you must take it twice a day. A second must be taken only once a day, but it costs more."
  • "If you become too sick to speak with me about your healthcare preferences, with whom would you want me to speak?"
  • "Do you have any specific concerns that you would like to share with me?"
  • "In some states, your preference to forgo a feeding tube if you are terminally ill or in a prolonged coma is only honored if it is written down in your advance directive."
With people diagnosed with a serious illness
Content of DiscussionsAction ItemsSuggested Communication Strategy
  • Same as above.
  • What is important for you now (values, beliefs, psychosocial needs)?
  • Discuss treatment burden and potential adverse-outcome states.
  • Discuss time-limited trials of treatments (not "never" vs. "always")
  • Discuss likely course with proposed treatments and likely outcomes.
  • Discuss what the next steps could be in the follow-up and management of the patient's condition.
  • Same as above.
  • MD discusses prognoses and outcomes, with and without recommended treatments.
  • MD/RN talks to surrogate.
  • MD/RN offers spiritual support.
  • "I anticipate that you will have a good recovery from this stroke. We are going to treat you with a blood thinner that will substantially reduce your risk of a further stroke. However, the risk is not zero. It is important that you plan ahead. Do you have any concerns or thoughts about your medical care if you do not have a good recovery?"
  • "Unlike TV shows, resuscitation is rarely effective when your mother has a serious illness like a stroke that produces unconsciousness."
  • "What do you know about what is likely to happen?"
With people diagnosed with a serious illness that will limit life expectancy, or coming to the end of a long life
Content of DiscussionsAction ItemsSuggested Communication Strategy
  • Same as above.
  • Explicit discussion about courses of potential treatments, likely outcomes, individual economic consequences.
  • Discussion of time-limited trials of treatments.
  • What is important for you to accomplish in the time you have left?
  • How can I help you achieve this?
  • Same as above.
  • State specific preferences and formulate contingency plans.
  • Be sure that key decisions are written down and transferred with the patient.
  • "Mrs. X, your breathing is really a problem for you almost all the time now. Tell me a little about your thoughts. In this part of your life, what makes you truly happy? What makes you worried or upset? What do you think will happen? What do you hope for? What do you hope to avoid? What do you expect the end to be like?"
  • "You said that you want medical care to focus on comfort. Even if you get more short of breath, you want to stay home. Is that correct? If you do get short of breath, and it does not respond to usual treatments, we will use morphine and your family can call..."

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