Northeast Florida Medicine, Spring 2016

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28 Vol. 67, No. 1 2016 Northeast Florida Medicine DCMS online . org
CME
Introduction
Advance care planning (ACP) is a process of understand-
ing, reflecting and discussing goals, values and preferences
for future healthcare decisions. ACP should be integrated
into routine medical care and practiced across the contin-
uum of care in all health settings and in the community.
Most everyone in health care today, especially those in
acute-care settings, has heard of the term“advance directive.”
When the U.S. Congress passed the Patient Self-Determi-
nation Act in 1991, the law mandated that hospitals and
other specific health providers establish policies and pro-
cedures to comply with the Act’s requirements.1 Hospitals
began to ask patients at admission if they have an advance
directive. Some also created brochures or handouts to help
educate patients and families.
This approach has not been effective, resulting in a low
number of completed documents, documents that are not
available when needed, and information in documents that
is not clear when presented.2 Nationally, among severely
or terminally ill patients, fewer than 50 percent have an
advance directive in their medical record.3 Between 65
percent and 76 percent of physicians whose patients have
an advance directive were not aware that it existed.4
In Northeast Florida, several hospitals reviewed medical
records of patients who died in those hospitals during a three-
month period in 2013. Aggregate data analysis following that
review showed there was an advance directive on the medical
record only 14 percent of the time. This demonstrates a
significant opportunity to improve care in our community.
What is Honoring Choices® Florida?
Honoring Choices® Florida (HCFL) educates the com-
munity on the benefits of and builds the infrastructure
necessary to expand adoption of advance care planning.The
true value of ACP lies in the conversation, as individuals are
given the opportunity to explore and discuss their values,
beliefs and life experiences. HCFL trains facilitators who
help patients explore and talk about their wishes should
they be faced with a serious or life-limiting illness. It has
been launched in Northeast Florida with the goal to spread
throughout the state of Florida.
HCFL is modeled after Respecting Choices®, a pioneer
program in advance care planning based in La Crosse, Wis-
consin. GundersenLutheranHospital inLaCrosse embarked
on this journey more than 20 years ago. Studies show that
96 percent of patients who die in hospitals in that region
have an advance care plan. The written plan is on the chart
99 percent of the time and patients receive care consistent
with their wishes 99 percent of the time.4
How is this approach to planning
different from other approaches?
The HCFL model views the planning process as more
complex and challenging than simply asking questions
required by law and handing out a form or brochure.
Trained facilitators guide conversations to help participants
understand their health care treatment options, clarify their
goals, make decisions about the appointment of a surrogate
decision maker, put a written plan in place, communicate
wishes and share documents with family, friends, clergy,
physicians and other health providers. Facilitators also:
- identify and explore the person’s fears, concerns and gaps
in understanding and address these issues as needed;
- review the person’s experiences of illness and medical
decision-making and assist him or her to use those
experiences in advance care planning decisions;
- explore the person’s values, goals and beliefs and consid-
er the importance of each relative to the person’s illness;
Advance Care Planning:
Infrastructure for Having the Conversation
By Andrew P. Daigle, MD & Jamie Buller, LCSW, ACHP-SW
Address correspondence to:
Jamie Buller, Director of Advance Care Planning
Community Hospice of Northeast Florida
4266 Sunbeam Road
Jacksonville, FL 32257
Andrew P. Daigle, MD
Senior Medical Director
Community Palliative Consultants
4266 Sunbeam Road
Jacksonville, FL 32257