Advance care planning (ACP) involves making decisions and plans about your future health care before you reach a time when you are no longer able to make those decisions or communicate those decisions well. Advance care planning involves reflecting on your life goals and values, selecting someone who can make decisions for you when you are unable to, and talking about your wishes with that person. Once you have had that conversation, a form can be filled out with signatures from two witnesses or a notary and given to your physician to keep in your medical record.
Advance care planning has been shown to improve the last years of your life, decrease health care costs at the end of life, and reduce the stress, anxiety, and depression experienced by the family and caregivers. Despite the benefits that come with advance care planning, only a small number of people complete these forms and research shows that African Americans and Latinos have lower rates of advance care planning than the general population. There are many possible reasons for this, including but not limited to: institutional and cultural barriers, mistrust of the medical system, language barriers, hesitancy for religious and spiritual reasons, low health literacy, and an emphasis on the family unit as the primary caretaker for a patient throughout the course of their disease.
In the Los Angeles County Department of Health Services (L.A. County DHS), there is a large and diverse population consisting of Latinos, African-Americans, and Asians, representing 2/3 of the population, and 12% of the population is over the age of 65. There is a growing need to spread awareness about the benefits of advance care planning and to make it easier to understand for our aging, diverse population in Los Angeles. Dr. Jessica Kaltman, a research fellow and physician affiliated with UCLA, believes that advance care planning is not just for the elderly. She states that “Advance care planning is a spectrum and should be discussed with a patient from a younger age, and as people age, the conversation can change.” Fortunately, there are already programs underway that are trying to address the problem of low completion rates of advance care directives.
Dr. Jessica Kaltman and Dr. Arpan Patel are trying to change the taboo around advance care planning through a pilot program started in collaboration with doctors at Martin Luther King (MLK) Jr Outpatient Center. The pilot program has a novel approach to make advance care directives a simpler, more fluid process that is incorporated into a doctor’s visit. First, medical assistants educate patients about what advance care planning is during the clinic visit. Patients also receive educational pamphlets that explain advance care planning in a culturally sensitive manner. Finally, the team has simplified the process of uploading advance directives into electronic medical records. They hope in conjunction these three approaches will increase the number of completed advance care directives in L.A. County DHS and change the way people view advance care planning.
At Olive View-UCLA Medical Center in the L.A. County DHS, Dr. Heather Schickedanz, a geriatrician and UCLA assistant professor, is also increasing awareness about advance care planning and directives. Her program also has three phases of implementation. The first phase involves offering eligible patients a 4-minute video that introduces advance care planning and advance directives on a tablet, while they are waiting to be seen by a primary care provider. Once patients have seen the video, a medical assistant provides an easy-to-read advance directive to discuss with their provider. This video based-education approach provides an avenue for both patients and the care team to feel more comfortable talking about goals of care. The second component involves group visits between a small group of eligible patients who have not completed an advance directive, their primary care provider, and a social worker. The group visits allow patients to ask questions and talk together about the sensitive issues that may come with advance care planning. It also provides space and time for this important topic, for the patient as well as the provider. As at the MLK clinic, the third phase integrates documentation of the advance care plan and advance directive into the electronic health record, making it easily accessible whether the patient is in the emergency room, hospital or in the clinic. Dr. Schickedanz’s goal is to improve the process and communication of advance care planning for our patients, so that their families and care teams will know and respect their wishes.
If you have any questions about advance directives or talking about what advance care planning means to you, we are interested in hearing about it! The physicians mentioned in this article would love to get your feedback and encourage you to comment on this article.