The need for safeguards in advance care planning

Abstract

The recent uproar about Medicare “death panels” draws attention to public and professional concerns that advance care planning might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy of a decisionally-incapacitated patient when choices about life-sustaining treatments are encountered. Unfortunately, patients often do not understand their decisions or may change their mind without changing their advance care directives. Likewise, concordance between patients' wishes and the understanding of the physicians and surrogate decision makers who need to represent these wishes is disappointingly poor. A few recent reports show encouraging outcomes from advance care planning, but the bulk of studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may undermine autonomy by leading to choices that do not reflect patient wishes. Safeguards for advance care planning should be put in place, such as requiring clinicians familiar with the patient's prognosis and treatment options to participate in the formulation of directives, assuring regular review of decisions, allowing physicians to err on the side of preserving life when uncertain about the application of an advance care directive, specifying the role of the health care proxy in interpreting or even overriding directives, requiring specialised counselling for non-emergent choices to limit life-sustaining treatment, training and certification of clinicians for conducting such conversations, and use of structured formats, clinical guidelines, and system support aides that promote quality and safety. Finally, associated research needs are outlined.