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Publication Briefs

Study Shows Missed Opportunities for Providers to Discuss Advance Care Planning with Veterans with Heart Failure

Research has shown that patients with heart failure (HF) want to understand the trajectory and prognosis of their disease as early as at the time of diagnosis, and that they prefer physicians to initiate such discussions. To help patients with HF prepare and plan for future care, early and regular patient-provider communication about prognosis and preferences for care is critical, but few studies have evaluated what is actually said in practice. This study sought to identify and characterize potential opportunities for physicians to engage in advance care planning (ACP) discussions – and to examine their responses to opportunities during follow-up with Veterans recently hospitalized for HF between 2005 and 2009. Using data from 71 audio-recorded outpatient clinic visits between 52 Veterans (age 65 or older) with HF and 44 VA physicians (primary care internist or cardiologist) at two VAMCs, investigators examined: 1) Veterans’ statements pertaining to their future health or their future physical, psychosocial, and spiritual/existential care needs, and 2) subsequent physician responses to patient statements.


  • In 13 of 71 outpatient consultations, Veterans expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians changed the subject back to the routine biomedical aspects of the visit; hedged their response about prognosis; denied or contradicted the patient’s expressed emotion or preference; or inadequately acknowledged the question or sentiment underlying the patient’s statement.
  • Reasons suggested for these missed opportunities include: physicians being unaware of the openers patients offer; lack of time to address multiple topics during a clinic visit; and discomfort some physicians face when discussing the possibility of their patient’s decline or death.
  • In order to successfully leverage opportunities to engage in ACP discussions, authors suggest that communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses.


  • Because this study was limited to audio recordings, investigators were unable to evaluate non-verbal communication behaviors.
  • Despite assessing a cross-section of clinic visits, investigators were unable to determine if ACP discussions had occurred previously. Documentation of advance directives also was not available for this study.

This study was funded by HSR&D (ECV 02-254). Drs. Ahluwalia and Lorenz are part of HSR&D’s Center for the Study of Healthcare Provider Behavior, Sepulveda, CA; Dr. Gordon is part of HSR&D’s Center for Management of Complex Chronic Care, Hines IL.

PubMed Logo Ahluwalia S, Levin J, Lorenz K, and Gordon H. Missed Opportunities for Advance Care Planning Communication During Outpatient Clinic Visits. Journal of General Internal Medicine October 25, 2011;e-pub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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