Advance care planning in family medicine training

Kiran Dhillon; Dave Jerome; Rajiv Teeluck; Yan Yu

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Table 1.

Introduce, Discuss, Decide, and Document framework: Use the following framework for ACP discussions.

FRAMEWORK ELEMENT	HOW TO APPLY
Introduce	Begin ACP discussions by ... Introduce the topic: “Can we talk about where things are with your health, and where things might be going?” Seek permission: “Is this okay?” Inform: Explain what ACP is and why it is important. Describe the process. Tell the patient that his or her decisions can be revised as health status or life situations change Follow up, if appropriate: After introducing the patient to the topic of ACP, consider having the patient return for a dedicated appointment to continue the rest of the process
Discuss	Assess a patient’s understanding “How much do you (or your family) know about your illness?” “What information would you like from me?” Determine a patient’s goals “What are the most important things you want to do in life?” “What are some abilities in life that you cannot do without?” Ask a patient about his or her fears “What are your biggest fears and worries about your health? Or about life in general?” Explore a patient’s trade-offs “If you get sicker, what kinds of health care services are you willing to endure to gain more time?”
Decide	Make decisions Patient should decide on who will be the SDM (“If you are unable to speak for yourself about medical decisions, who do you want to speak for you?”) You need to decide which patient-centred principles are based on, and comply with, the values that the patient has identified as being most important to his or her life This component of the ACP discussion might require multiple discussions if there is no medical indication for an urgent decision
Document	Include documentation of certain factors Document the designation of the SDM. The patient should ensure that the SDM is aware of his or her role and is informed of the patient’s priorities and wishes Document any principles-of-care decisions that have been made Ensure that documentation complies with relevant provincial, territorial, or regional regulations regarding the documentation of designated SDMs and decisions specifying principles of care

ACP—advance care planning, SDM—substitute decision maker. Dialogue prompts adapted from Ariadne Labs.⁹

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Table 2.

When to have an ACP discussion with your patient

HEALTH STATUS	ACUITY	ACTIONS
Patient who is well	Nonurgent	Have a full, focused ACP conversation during periodic health examinations and when important life events occur (eg, marriage, pregnancy, new job) Emphasize choosing an SDM
Patient with chronic disease	Semiurgent	Have a full ACP conversation during each periodic health examination and when triggered by medical events (eg, new diagnosis, discharge from hospital) If the patient is living with chronic disease, discuss the disease course and potential health outcomes as the disease progresses and at decision points that might arise in the future Revisit at regular intervals as appropriate
Patient with acute deterioration in health	Urgent; decision needed now	Revisit the ACP conversation with the patient or SDM, or initiate the discussion if this has not already been done Discuss code status or goals of care with the patient or SDM at this stage Recommend best treatment based on the patient’s goals, fears, values, and his or her specific illness context Emphasize immediate or anticipated health care decisions