Advance Care Planning Intervention

Abstract

Kirchoff and colleagues1 understate the value and important implications of their exceptional study. It is one of only two randomized controlled studies now available on the effect of a model advance care planning intervention for ambulatory individuals at high risk of facing end-of-life decisions. It demonstrates excellent design, the feasibility of such a study, and the use of a patient-centered advance care planning module. Following patients over 3 years, the authors show that approximately one-third of high-risk patients die and that one-quarter of these become decisionally incapacitated at the time of death. Thus, advance care planning has the potential to influence the care of approximately one-twelfth of high-risk individuals (as defined by them) within a reasonable period of time in which to consider an advance care plan as valid.2 Moreover, given the data on the number of incapacitated individuals who did not receive the intervention and whose wishes were not met (13%), as few as approximately 1% of high-risk individuals could directly benefit from an advance care directive. If, as the study suggests, preparing an advance care directive will have little overall influence on choices about life-sustaining treatment, the question arises as to the need for allocating resources to this procedure, especially in individuals at low risk of having to make end-of-life decisions. Although clinicians may readily recall troubling situations in which advance care directives were sorely needed, such as the Terri Schiavo case, few similar events may actually occur. Nevertheless, an earlier randomized controlled trial showed beneficial outcomes of advance care planning in multiple aspects of family well-being.3 Previous researchers have suggested that the original goal of advance care planning—assuring end-of-life care congruent with the incapacitated individuals wishes—should be of secondary importance.4, 5 Instead, they advise focusing on the value of early communication about end-of-life care in preparing anyone for future end-of-life decisions and in assisting all families and healthcare proxies when faced with difficult choices about life-sustaining care. Conflict of Interest: None. Author Contributions: Interpretation of data and preparation of manuscript. Sponsor's Role: None.