Blueprint for scaling advance care planning conversations to medical practices

Abstract

Summary Establishment of the Community Conversations initiative in Schenectady County, New York began as a response to pleas from palliative care professionals who recognized the absence or paucity of Advance Directives (AD) in the medical records of referred patients. The palliative care physicians responsible for cases of the critically ill or those with diminished or no decisional capacity often faced the challenging task of locating a previously prepared AD, if any, identifying a healthcare proxy or agent who could speak on behalf of the patient (in terms of best interests or substituted judgment), or identifying clear and convincing evidence as to what, if any, life-sustaining treatment was expressed prior to illness. Practitioners and patients, both in the US and France, have historically avoided the confrontation and “the conversation.” Similarly, examination of shared decision making training programs evidenced wide variations in how and what they deliver. More importantly, evidence of their effectiveness was sparse. Studies on shared decision making programs suggest there is a need for international consensus on ways to address the variability in patient-centered programs concerning “the conversation” surrounding Advance Care Planning (ACP).