Advance care planning in family medicine training

What is ACP?

Advance care planning is a process that includes reflection and communication about a patient’s values, beliefs, goals, and preferences to best prepare for his or her future medical care. The designation of a substitute decision maker (SDM) is a key element of ACP.¹

Why is ACP important?

Up to 76% of patients will be unable to participate in some or all of the decisions affecting their own health care at the end of life,² and 47% of Canadians have not had a discussion with a family member or friend about what they would want or not want if they were ill and unable to communicate.³ Without the direction provided by ACP, families often feel burdened by directing medical care in crisis situations and might feel ill-prepared to make decisions owing to a lack of understanding of the patient’s values and preferences. When no previous direction has been documented, physicians often resort to using full resuscitative and medical care. This can mean aggressive treatments that the patient might not have wanted, and might result in unnecessary suffering for both the patient and family members.

Previous research has highlighted numerous benefits of ACP, including the following: improved quality of end-of-life care⁴; improved patient and family satisfaction with end-of-life care⁵; reduced stress and anxiety for families⁵; reduced hospital admissions and length of stay⁶; increased use of hospice care⁶; and shorter stays in the intensive care unit.⁷

Why is ACP important in family medicine?

Family physicians have long-standing relationships with their patients. They are the health care professionals who best know the health status, personal priorities, and social context of their patients. Furthermore, they have the advantage of being able to engage in the ACP process over several visits. For these reasons, family physicians are best positioned to conduct these sensitive conversations with their patients.⁴

Despite the importance of ACP in family medicine, there is a lot of discomfort and uncertainty among resident physicians when engaging in ACP with patients. Based on the results of a survey, only 40% of family medicine residents at Canadian institutions think that they are prepared to guide patients in ACP discussions following their residency (K.D., D.J., R.T., Y.Y., unpublished data, December 2016). This discomfort appears to carry over into practice, as a national survey showed that 26% of practising primary care physicians are comfortable leading ACP discussions with their patients and 67% believe they need more resources in order to do this.⁸

Approach to ACP conversations

Most (80%) family medicine residents indicated that a clinical aid or how-to guide would be helpful for performing ACP (K.D., D.J., R.T., Y.Y., unpublished data, December 2016). To address this need, we conducted an extensive review of ACP literature and existing resources, as well as engaged in consultations with education and ACP experts, and then devised a simple framework for ACP: the Introduce, Discuss, Decide, and Document (ID3) framework (Table 1).⁹ The goal of this framework is to provide structure for ACP discussions and it is not meant to replace formal ACP instruction and education.

How to perform ACP

Consider the following when performing ACP with patients.

• Triage the discussion according to the patient’s health status (Table 2).

• Check for and review previous ACP conversations.

• Plan for a serious discussion in an appropriate setting. (For patients who are well, this discussion might take only a couple of minutes; for patients with more serious conditions, this conversation will take some time.)

• Encourage the patient’s SDM to be present for ACP discussions.

• Use the ID3 framework during ACP discussions (Table 1).⁹

• Revisit the ACP discussion over multiple visits or discussions as appropriate given the patient’s health status.

The ID3 framework for ACP discussions

The ID3 framework provides an approach for clinicians to conduct ACP discussions. It might not be possible or appropriate to complete the full ID3 process during a single discussion. Between appointments, encourage patients to review patient resources from the Speak Up campaign website (www.advancecareplanning.ca) and to discuss their values and preferences with their family members and SDMs.