How do we “advance” Advance Care Planning during COVID?

How do we “advance” Advance Care Planning during COVID?
June 22, 2020 Center for Surgery and Public Health

How do we “advance” Advance Care Planning during COVID?

by Claire Sokas, MD and Zara Cooper, MD, MS with policy contributions from Amanda Reich, PhD, MPH and Esther Moberg, MPH

Part of the CSPH Series “What Comes Next: the Impact of COVID-19 on Surgery”

As I attempted to explore their thoughts about intubation – with the patient alone, scared, and in pain – I found myself insufficiently prepared to guide this advanced care planning (ACP) conversation in suboptimal conditions.

“Doc, is it even safe to be here?” I was in the ED on a Saturday night in April, seeing a patient needing emergent abdominal surgery. He, his wife and I were discussing his condition, the likelihood he would need surgery, and the impact his pre-existing conditions would have on his course. While I have had similar conversations many times before, I was frustrated – between my N-95 and the general hustle and bustle of the emergency room (ER), it was difficult for the patient to hear me, let alone for his wife who was on speaker phone. Due to COVID protocol, his wife was sitting in a parking lot 100 yards away unable to come inside. The patient was expressing guilt for delaying his presentation to the ER by almost a week due to fear of COVID and the hope that he would just “feel better.” He was scared and physically alone, with his COVID test pending. As we talked about the implications of his diagnosis, I discovered that he and his wife had not previously discussed the potential for prolonged intubation – with his lung disease and current diagnosis, I felt this to be a distinct possibility with, or, without COVID. As I attempted to explore their thoughts about intubation – with the patient alone, scared, and in pain – I found myself insufficiently prepared to guide this advanced care planning (ACP) conversation in suboptimal conditions.

Before the COVID pandemic, it was rare that I spoke with a patient about care, such as prolonged intubation, without engaging family and friends at the bedside. Having additional voices in the conversation helped offer context regarding the patient’s goals, clarify gaps in understanding, and provide emotional support. In the COVID-era, where decreasing social contact is necessary, clarifying patient goals and values while engaging all relevant parties remotely is a constant challenge.

Having additional voices in the conversation helped offer context regarding the patient’s goals, clarify gaps in understanding, and provide emotional support.

Advance care planning, or ACP, is a process that supports adults at any age or stage of health in understanding their personal values, goals and preferences for future medical care. Oftentimes, ACP is understood as the outcome of these conversations – documentation of a surrogate decision maker/health care proxy, and specific legal documents for healthcare decision making (durable power of attorney, living will, physician orders for life saving treatment). Or, in the case of my perforated diverticulitis patient in the ER, the potential for prolonged intubation.

In an ideal situation, advanced care planning is proactive and integrated into routine care, in a comfortable, low-stakes environment. However, the COVID pandemic has upended both traditional healthcare and ACP and forced healthcare providers to rethink and restructure the delivery of care. The effects of social distancing are often felt most acutely when guiding conversations about preference-sensitive care – sensitive bedside conversations have been replaced with teleconferences, and in many cases family and friends have never met those providing care for their loved ones face-to-face.

[T]he COVID pandemic has upended both traditional healthcare and ACP and forced healthcare providers to rethink and restructure the delivery of care.

The COVID pandemic has served to highlight the need for prior advanced care planning, however, even post-pandemic advanced care planning and the often emotionally charged family conversations that come along with it, will continue to be important. There are many existing opportunities to improve the process and outcomes of ACP.

TRANSFORMING POLICY & PRACTICE

The ongoing pandemic has provided an opportunity to rethink policy and integrate ACP across healthcare services: The need for care planning exceeds the supply of palliative care specialists. The following include components of palliative care that all providers can integrate into their care delivery:

There are a variety of strategies to simplify advance care planning to improve patient-provider communication.

Use visual aids to guide patient-centered discussions: leverage technology and telemedicine by using simple, hand-drawn or computer graphics such as Best Case – Worst Case to:

  • Illustrate choice treatment options
  • Engage patients and families in conversation
  • Confirm understanding of all parties involved

Empower and educate: Provide patients, their families, and their surrogate decision makers with resources. There are many user-friendly online resources to help patients and their loved ones continue conversations about their goals.