Abstract

The patient self-determination act was effective in lifting advance directives (AD) as a recognised and accepted tool to document treatment wishes but did little to increase the completion of AD (29% Americans complete AD), ensure wishes are honoured or ensure an AD is available to assist in decision making. Success in honouring wishes is possible if there is commitment to:

1. Endorse standards which support infrastructure and processes to introduce and encourage advance care planning (ACP).

2. Build systems to document wishes, store/retrieve AD, and referral mechanism to access resources.

3. Educate, train and provide access to staff for facilitating three levels of ACP (basic, complex, POLST).

4. Develop patient education materials and engagement strategies to promote ACP completion.

5. Adopt policies, ongoing quality and process improvement strategies to identify gaps in the systems to honour wishes.

A large Midwest health system has been successful in maintaining these five ACP commitments over a five year period as demonstrated by:

1. Ten thousand clinicians and volunteers completing ACP education and training (new employee orientation standard).

2. Prevalence AD in the medical record for those discharged alive and dead (16% vs. 38%, 15% vs. 30%).

3. Completing 16,313 facilitated ACP discussions by trained staff with completed health care directives, disease specific statement of treatment preferences or POLST (provider order for life sustaining treatments).

4. Increasing access to ACP resources (400 to1200 ACP referrals/month).

5. Centrally locating ACP documentation across settings.

6. Establishing ACP reimbursement.

7. System wide accountability of ACP.