Innovations in Advance Care Planning

As an Elder Law attorney, I strive to ensure that all individuals know the importance of documenting their end of life wishes. Here is an interesting article about a new way in which those in the medical profession are working to document the wishes of their patients.

A Novel Way to Document End-of-Life Preferences

By Paula Span

Maybe we’ve been going about this all wrong.

In the continuing campaign to get people, particularly the old and sick, to discuss their preferences for end-of-life care, we’ve been pushing for them to have intimate conversations with family members.

Web sites like The Conversation Project and PREPARE, campaigns like National Healthcare Decisions Day in April, my own posts here — all reflect the idea that Americans can overcome their apparent aversion to acknowledging mortality if their children will just talk to them.

Progress on this front has been slow, however. Pew Research surveys found in 1990 that 12 percent of Americans had a “living will,” a figure that rose to just 29 percent by 2005. So on a nearly daily basis, the palliative care specialist Dr. Joshua Lakin told me in an interview, “I’d see someone who’d had lung cancer for several years, who’d been in and out of the hospital, had seen 20 doctors, and still hadn’t thought about the future and his priorities. It kind of blindsided me.”

So Dr. Lakin, who just completed a fellowship at the University of California, San Francisco, and some colleagues took an entirely different approach to what is called advance care planning. They experimented with brib . . . er, incentivizing doctors. And whaddya know, it worked.

As the team reported in JAMA Internal Medicine last week, the UCSF Medical Center has an incentive program to improve quality; each year its doctors-in-training pick one area to focus on. For the 2011-2012 academic year, the internal medicine department decided to concentrate on documenting patients’ advance care decisions.

The researchers came up with a standard form, which was inserted in patients’ electronic health records. It asked just a few questions: Does the patient have any “expressed wishes” about how much care he wants or doesn’t? Where are those preferences recorded — in a living will, a durable power of attorney, a P.O.L.S.T. form (which would be scanned into the record). Or are they expressed orally?

The researchers’ form requests a brief summary: He doesn’t want to be resuscitated or intubated? She wants a feeding tube but not a ventilator? Or she wants “all available care?” Does he have a designated decision maker? What is that person’s name and phone number, and what language does he or she speak?

If residents recorded this information for at least 75 percent of discharged patients, for three of the four quarters in the academic year, they each got a $400 bonus. If not, they didn’t.

The hospital, not the researchers, established that sum, but “it was enough to get people motivated,” Dr. Lakin noted. Residents around the country earn between $40,000 and $50,000 a year, plus housing stipends. An additional 400 dollars isn’t life-changing, but it’s not pin money, either. And the researchers sent out bar graphs via e-mail to point out if teams were hitting the goal or endangering everyone’s bonus. (“Marketing 101,” Dr. Lakin called it.)

The experiment followed nearly 1,500 patients, more than half the adults (of all ages) seen by the hospital’s medical department that year.

In July, the first month, only about 22 percent had their preferences documented, roughly the same proportion as before the incentives began. So “the template itself wasn’t enough,” Dr. Lakin said.

But by October, following Marketing 101, the proportion of patients with documented preferences hit 90 percent and stayed there. By contrast, a separate team of attending physicians who didn’t participate in the incentive program averaged less than 12 percent for the year.

So maybe we don’t have to keep nudzhing our parents, bracing for uncomfortable discussions. Maybe a doctor, at a hospital or not, can do this in 10 minutes without angst.

Of course, the study doesn’t answer some major questions. We don’t know how much of an incentive, if any, would motivate practicing physicians, who are paid more than residents. We also don’t know whether simply having a standard form in your medical records means that you will actually have your wishes respected — that you’ll be put on a ventilator if you said you’d want that, but not if you said you didn’t.

But we do have some idea of the scenario that ensues when people have never discussed their wishes. The medical conveyor belt cranks up. “There’s a set of default choices in the hospital system, which does things unless told not to,” Dr. Lakin said.

I’d still rather have the family conversation. But so often, it never takes place. Stricken families, sometimes bitterly at odds, wonder what Mom would want if she could speak. Maybe nobody really knows. Maybe, for a paltry sum compared with the cost of a single day in intensive care, her doctor could have found out.