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End of Life Issues

Advance Care Planning and the Primary Care Physician

August, 2002


Primary Care Physicians are the link to medical care for their patients. As such, they are the ones who institute screening for diabetes, cholesterol, cancer, smoking, etc. Equally important as other screening tools is the introduction of advance care planning for patients at the time of annual exams. At that time, patients are prepared to look at all aspects of their lives and it is perfectly appropriate for them to explore what they would want done medically if they were no longer able to make decisions for themselves. They need not complete the advance care directive at that time, but the health care practitioner can introduce the topic, literature can be given, and an appointment to talk with someone knowledgeable about advance care planning can be made.

Ideal Advance Care Planning

Successful community programs for advance care planning have utilized a variety of approaches.

  1. It is helpful to have information in the doctors' waiting rooms.

  2. Studies have shown that people are more likely to complete advance care directives if they are asked about them at their doctors' offices. As part of the intake, nurses might ask about Advance Care Planning (ACP) in the same way that many of them now ask about smoking. Doctors have made Advance Care Planning part of annual physical exams.

  3. In larger clinics, one person has been designated as the counselor for ACP. They have a special interest and may have been trained by the local hospice professionals in the details. Patients who are interested in contemplating these issues will make an appointment with this person.

  4. The presence of an Advance Care Directive (ACD) and a durable medical power of attorney can be placed on the front of the chart along with the problem list.

  5. Lawyers may include ACP in estate planning.

  6. Communities may arrange ACP days where doctors, social workers, and lawyers take part in a panel and there is an opportunity to complete one's ACD after the panel discussion when volunteer lawyers and doctors are available to answer questions.

  7. Communities have had screenings of "On Our Own Terms," the Bill Moyers' special that looked at end-of-life issues. This four-part series has fostered discussions that have been facilitated by medical and/or social work personnel knowledgeable about end-of-life issues. The book and movie, Tuesdays with Morrie and the play Wit have also been used as springboards for community discussions.

  8. Hospitals have kept ACDs in a file so that community members have access to their files wherever they are in the world when they are needed.

  9. Some hospitals keep the ACD and the durable power of attorney for health care in a special colored sleeve so that these items can be easily located for every patient.

  10. Some churches have sponsored seminars and discussions for introduction of ACDs to their parishioners.

  11. There is no one way that is perfect for every community, but we can learn from each other. Multiple approaches in each community are most effective.

How to Get Started

  1. Ask every patient at the time of their annual exam if they have completed an ACD and a durable power of attorney for health care.

  2. Keep appropriate forms in your office. These can be printed from the Internet or, perhaps, obtained from your local hospice. The exact forms do differ from state to state.

  3. Add a line to your problem list to indicate the ACP status of the patient.

  4. Contact your local hospice to see what is already going on in your community. Give them a copy of this handout to suggest other ideas.

  5. Consider training one interested person from your clinic to be your local expert.

  6. Complete your own ACD and durable medical power of attorney and ask your family members to do so as well.


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