Missed opportunities for advance care planning in primary care.

Ahluwalia SC, Levin JR, Lorenz KR, Gordon HS. Missed opportunities for advance care planning in primary care. Paper presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ.

Related HSR&D Project(s)

• ECV 02-254 – Physician-Patient Communication in Patients with Chronic Heart Failure

Background Advance care planning (ACP), a process of patient-provider communication by which a patient can make their preferences for future care known, is particularly relevant for patients with heart failure (HF) , who face a highly variable trajectory characterized by periods of medical crisis, and where considerable uncertainty exists about the timing and nature of death. Early and regular ACP for these patients fosters a shared understanding of a patient's wishes for care than can usefully guide future care. There is indirect evidence to suggest that ACP discussions are limited in the primary care setting; such discussions are often avoided until death is imminent. A key barrier to engaging in ACP reported by primary care clinicians is the lack of opportunity during a busy clinic visit to raise this complex topic with their patients. The purpose of this study was to 1) determine the frequency and type of ACP communication between HF patients and their primary care providers (PCP) during clinic visits following discharge from a HF hospitalization and 2) to characterize missed opportunities for engaging in ACP during the visit. Methods Content analysis of 76 unique post-discharge primary care clinic visits, recorded and transcribed, with veterans > 65 years with heart failure (HF) and their primary care physician. Transcripts were analyzed for the occurrence of 5 components of ACP as defined by existing literature: explanation of disease trajectory, prognosis communication, discussion or completion of formal directives, discussion or identification of a surrogate decision-maker, and personal and psychosocial planning for the future. Transcripts were also analyzed using grounded theory methods for missed opportunities for providers to engage in ACP, defined as direct communication by the patient providing information regarding their thoughts, concerns, or questions related to any of the 5 components of ACP, that was not fully encouraged or adequately responded to by their provider. Results Out of the 76 unique clinic visits analyzed, only one contained a discussion of all 5 components of ACP. Of the remaining 75 visits, 15% (n = 11) included an explanation of disease trajectory, 23% (n = 17) included prognosis communication, 4% (n = 3) included a discussion of formal directives, 0% (n = 0) included discussion of a surrogate decision-maker, and 4% (n = 3) included personal and/or psychosocial planning for the future. The following categories of missed opportunities for engaging in ACP emerged from the analysis: i) emotional opportunities, where veterans expressed concern or worry regarding their prognosis, future functional abilities and likelihood of decline, or their overall expected health state, ii) information-seeking opportunities, where veterans sought information on their prognosis, specific treatment options, or future care, and iii) social-support opportunities, where veterans discussed their future health within the context of their family/caregiver or broader social environment. Categories of provider responses to these communications included: i) incomplete responses, where the physician did not fully explore the comment, ii) misdirected responses, where the provider bypassed the comment by engaging in a related discussion and iii) terminated responses, where the provider invalidated or ignored the veteran's thoughts or feelings. Conclusions These findings demonstrate particularly limited engagement in ACP by PCPs with their patients with HF. Patients actively seek information, empathy and guidance from their providers regarding their illness that may be overlooked or inadequately addressed by their provider. The missed opportunities for ACP identified here represent meaningful entrees into discussions about planning and preparing for future care; active recognition of these opportunities may help providers to initiate what is already a difficult and complex topic.