This webinar provides resources and guidance on effective conversations with patients and families about their goals, wishes, and values for end-of-life care.

1. Advance Directives and
Advance Care Planning
Ensuring Patient Voices Are Heard

2. CE Provider
Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social
Workers and Nursing Home Administrators through: VITAS Healthcare
Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved
By: Florida Board of Nursing/Florida Board of Nursing Home
Administrators/Florida Board of Clinical Social Workers, Marriage and
Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing
Home Administrators and Respiratory Therapists through: VITAS Healthcare
Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA
CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved
By the Illinois Division of Profession Regulation for: Licensed Nursing Home
Administrators and Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education
by the Association of Social Work Boards (ASWB) Approved Continuing
Education (ACE) program. Organizations, not individual courses, are approved
as ACE providers. State and provincial regulatory boards have the final authority
to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course.
ACE provider approval period: 06/06/2018 – 06/06/2021. Social workers
completing this course receive 1.0 ethics continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine,
CA 92602. Provider approved by the California Board of Registered Nursing,
Provider Number 10517, expiring 01/31/2021.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC:
No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA:
No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not
required – RT only receive CE Credit in Illinois

3. Goal
To educate healthcare clinicians about
advance directives and advance care
planning, as well as serve as a support
resource for those individuals.

4. Objectives
• Review the origin and meaning
of advance directives
• Define advance care planning (ACP)
• Identify the types of advance
directives and their function
• Provide guidance and resources
on advance directives

5. What Is
ACP?
Per the National Hospice and Palliative
Care Organization (NHPCO): “Advance
care planning is making decisions about
the healthcare you would want to receive
if you’re facing a medical crisis. These are
your decisions to make, regardless of
what you choose for your care, and the
decisions are based on your personal
values, preferences, and discussions
with your loved ones.”
National Hospice & Palliative Care Organization, Advance Care Planning. Retrieved from:
https://www.nhpco.org/patients-and-caregivers/advance-care-planning/

6. What Is
ACP?
Communication:
• Frequent, ongoing patient-clinician
conversations about end-of-life (EOL)
care values, goals, and preferences
• Conversations among patients, their loved
ones, and their healthcare team—with
consideration of the patient’s relationships
and culture—to explore EOL treatment
options and make decisions about
care preferences
• These decisions can then be recorded
in an advance directive (AD)

7. What Is
ACP?
Support throughout the disease process:
• Help people at any age or stage of
health understand and share their
values, goals, and preferences
regarding future care
• Discussion goals and timing vary; they
are based on a person’s health, values,
culture, and a multitude of factors that
can influence decision-making

8. VITAS
Survey Data:
Post-COVID,
Consumer
Interest
Grows in
ACP
VITAS-sponsored Ipsos survey of 1,000 Americans, March 2021.
VITAS survey data from 2021 finds growing
interest in talking about end-of-life wishes:
• 69% of consumers say discussing EOL
wishes is important; 56% have done so
– 32% have documented their wishes
in writing
• 29% said the pandemic increased the
likelihood of documenting their wishes
• 20% knew someone who was seriously
ill or died during the pandemic, but they
did not know that person's wishes/values

9. When
Should ACP
Discussions
Start?
VITAS-sponsored Ipsos survey of 1,000 Americans, March 2021.
The same poll identified key benchmarks
for triggering ACP conversations:
• 55% - At a certain age
• 38% - If they have a serious illness
• 24% - When they retire
• 22% - When their physician brings it up
Common barriers to ACP conversations:
• 42% - “I’m not sick or dying”
• 26% - “It’s depressing to think about”
• 23% - “I don't know how to create a plan”

10. Why Is ACP
Important?
“Many people nearing the end of life (EOL)
are unable to make their own care decisions”
Of people who indicate their EOL care
preferences, most choose care focused
on alleviating pain and suffering
The primary objective of ACP is to ensure
that patients receive care that aligns with
their goals and values
In 2018, 31% of US patients died at home,
yet surveys show 71% of Americans
would prefer to die at home
Institute of Medicine (IOM). (2014). Dying in America: Improving quality and honoring individual preferences near the end of life. Summary. Washington, DC: The National Academies Press.
Detering, K., et. al. (2018, May) Advance care planning and advance directives. Retrieved from https://www.uptodate.com/contents/advance-care-planning-and-advance-directives
Cross, S., & et al. (2019). Changes in the place of death in the United States. NEJM, 381: 2369-2370.
Kaiser Family Foundation & The Economist. (2017). Four country survey on aging and end-of-life medical care. Retrieved from:
http://files.kff.org/attachment/Topline-Kaiser-Family-Foundation-The-Economist-Four-Country-Survey-on-Aging-and-End-of-Life-Medical-Care.
Olaisen, R., (2020). QuickStats: Percentage of deaths, by place of death—National Vital Statistics System, United States, 2000–2018.

11. • Clinicians bear the responsibility
to initiate ACP discussions—but
are often uncomfortable,
inadequately trained, or too busy
• Public’s lack of knowledge of
purpose and procedure of ACP
• Most patients express a desire for
honest conversation—but wait
on clinicians to initiate it
• Lack of concordance with
wishes and care provided at EOL
Henage, C. (2020). Educational interventions to improve advance care planning discussions, documentation and billing. American Journal of Hospice & Palliative Medicine, 38(4) 355-360.
Johnson, S. (2018). How well do current measures assess the impact of advance care planning on concordance between patient preferences for end-of-life care and the care received
A methodological review. Journal of Pain and Symptom Management, 55(2).
Van Dyck, L., et al. (2021).Understanding the role of knowledge in advance care planning engagement. Journal of Pain and Symptom Management.
Retrieved from: https://doi.org/10.1016/j.jpainsymman.2021.02.011
ACP
Challenges

12. In a review of 150 US studies:
• 36.7% of population had completed
an advance directive
• 29.3% had completed a living will
with stated wishes for care
• 33.4% had appointed a healthcare
power of attorney
• Ill persons are more likely to have
completed documents than healthy
persons (38.2% vs. 32.7%)
• Patients ≥ 65 are significantly
more likely than younger adults
(45.6% vs. 31.6%)
Yadav, K., et al. (2017). Approximately one in three US adults completes any type of advance directive
for end-of-life care. Health Affairs, 36(7):1244-1251.
ACP
Challenges

13. ACP
Challenges
• Only 11% report having a
conversation about end-of-life
care with their healthcare provider
• Only 22% of those ages 65 and
older have had a conversation
with their healthcare provider
Kaiser Family Foundation & The Economist. (2017). Four country survey on aging and end-of-life medical care. Retrieved from:
http://files.kff.org/attachment/Topline-Kaiser-Family-Foundation-The-Economist-Four-Country-Survey-on-Aging-and-End-of-Life-Medical-Care.
Eggerston, L. (2013). Doctors, patients urged to discuss advanced care plans. CMAJ, 185(13): E617–E618.

14. ACP Challenges
Kaiser Family Foundation & The Economist. (2017). Four country survey on aging and end-of-life medical care. Retrieved from:
http://files.kff.org/attachment/Topline-Kaiser-Family-Foundation-The-Economist-Four-Country-Survey-on-Aging-and-End-of-Life-Medical-Care
Large Shares Would Be Comfortable Talking About End-of-Life Wishes With Doctors
How comfortable would you be talking about your own end-of-life medical wishes with each of the following?
86%
66%
60%
58%
53%
9%
26%
22%
23%
22%
2%
4%
6%
11%
9%
2%
2%
9%
6%
12%
Your spouse or partner*
A doctor or other health-care provider
Your children*
Your parents*
A ministrer, priest, or other religious or spiritual advisor
Very comfortable Somewhat comfortable Not too comfortable Not at all comfortable

15. Somewhat
oppose, 3%
Strongly
oppose, 1%
Supports,
95%
Strongly
support, 66%
Somewhat
support ,
29%
Somewhat
important, 10%
Not too/not at all
important, 1%
Extremely
important,
51%
Very
important,
38%
ACP
Challenges
Fulmer, T., et al. (2018). Physicians' views on ACP and end-of-life conversations.
Journal of the American Geriatrics Society, 66(6):1201-1205.
Figure 1. Responses to question: In your own
opinion, how important is it that healthcare
providers have advance care planning
conversations with patients?
Figure 2. Percentage of respondents who
support the new Medicare benefit paying
for advance care planning conversations.

16. ACP
Opportunities
• Educating and training clinicians
– Interdisciplinary and ongoing
• Public outreach
• Systems
– Documentation of ACP
– EMR reminders
• Reimbursement for ACP
Fulmer, T., et al. (2018). Physicians' views on ACP and end-of-life conversations. Journal of the American Geriatrics Society. 66(6):1201-1205.
Geerse, O. (2021). Adherence and concordance between serious illness care planning conversations and oncology clinician
documentation among patients with advanced cancer. Journal of Palliative Medicine, 24(1).
Henage, C. (2020). Educational interventions to improve advance care planning discussions, documentation and
billing. American Journal of Hospice & Palliative Medicine, 38(4) 355-360.
Van Dyck, L., et al. (2021).Understanding the role of knowledge in advance care planning engagement. Journal of Pain and
Symptom Management. Retrieved from: https://doi.org/10.1016/j.jpainsymman.2021.02.011

17. ACP and COVID-19
Ping, Y. (2021). Changes in advance care planning for nursing home residents during the COVID-19 pandemic. JAMDA. 22(209-214).
A recent study found that
nursing home residents
increasingly opted for Do
Not Resuscitate (DNR) and
Do Not Hospitalize (DNH)
options after having ACP
conversations with their
healthcare practitioners
during the COVID-19
pandemic.
361
602
188
273
690
455
Full Code OOH DNR DNH
Before ACP After ACP

18. ACP and
COVID-19
• Another study from the West Virginia
Center for End-of-Life Care noted a
“new sense of urgency regarding
advance care planning”
• Jan.-June 2020 vs. Jan.-June 2019:
– 9.05% increase in ACP form
submissions overall
– 77.18% increase in DNR cards
– 45.95% increase in e-Directive
Registry sign-up
Funk, D. (2020). How COVID-19 changed advance care planning: Insights from the West Virginia center for end-of-life care.
Journal of Pain and Symptom Management, 60(6).

19. ACP Outcomes
Silveira, M., et al. (2010). Advance directives and outcomes of surrogate
decision making before death. NEJM, 362:1211-1218.
* Percentages are weighted and were derived with the use of sampling weighs from the Health and Retirement Study. DPAHC denotes
durable power of attorney for health care.
Key Outcomes According to Advance-Directive Status Among 999 Subjects.*
Outcome
Living Will No Living Will
(N=44) (N=552)
% of subjects
Adjusted Odds
Ratio
(95% CI)
DPAHC No DPAH
(N=589) (N=407)
% of subjects
Adjusted Odds
Ratio
(95% CI)
Death in a hospital 38.8 50.4
0.71
(0.47–1.07)
38.2 55.8
0.72
(0.55–0.93)
All care possible 8.1 27.7
0.33
(0.19–0.56)
13.4 27.0
0.54
(0.34–0.86)
Limited care 80.6 66.0
1.79
(1.28–2.50)
75.4 68.1
1.18
(0.75–1.85)
Comfort care 96.8 91.3
2.59
(1.06–6.31)
95.9 90.6
2.01
(0.89–4.52)

20. ACP Outcomes
Wright, et al. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 300(14):1665-1673.
McGill Psychological Subscale* Total Yes (+ACP) No (-ACP) P value
adjusted least square means (SE) Sample
“Depressed” 7.4 (2.9) 7.3 (0.2) 7.4 (0.2) 0.79
“Nervous or worried” 6.9 (3.2) 6.5 (0.3) 7.0 (0.3) 0.19
“Sad” 7.2 (3.0) 7.3 (0.2) 7.2 (0.2) 0.79
Acceptance, preferences Total Yes No AOR (95% CI)
and planning, N (%) Sample
Accepts illness is terminal 125 (37.7) 65 (52.9) 60 (28.7) 2.19 (1.40-3.43)*
Against death in ICU 118 (35.5) 60 (48.8) 58 (27.8) 2.13 (1.35-3.37)*
Completed DNR order 134 (41.1) 75 (63.0) 59 (28.5) 3.12 (1.98-4.90)*
Completed living will, durable 181 (55.2) 86 (71.7) 95 (46.1) 1.96 (1.25-3.07)**
power of attorney, or health
care proxy
*Subscales of the McGill Quality-of-Life Questionnaire (scale 0-10) where 0 is undesirable and 10 is desirable.
N = 322 *P value < 0.001 **P value = 0.003
EOL Discussions Align Care With Patients’ Wishes & Values

21. ACP
Outcomes
Discussions About End-of-Life Care:
• 2x as likely to accept advanced diagnosis
• 2x as likely to be opposed to death in ICU
• 3x as likely to complete DNR
• Almost 2x as likely to complete a power
of attorney
• Give control back to patients and offer hope
• Are not associated with physiological
distress compared to those who do not
have end-of-life discussions
Wright, et al. (2008). Associations between end-of-life discussions, patient mental health,
medical care near death, and caregiver bereavement adjustment. JAMA, 300(14):1665-1673.

22. ACP
Outcomes
• Some studies show ACP conversations
improve multiple outcomes:
– Fewer hospital admissions and
intensive treatments at end of life
– Increased enrollment in hospice
– Greater likelihood of the person
dying in the setting of their choice
– Increased satisfaction
• A 2017 outcome review study was unable
to determine if ACP impacts EOL care.
Concordant care ranged from 14% to 98%
Teno, J. (2007). Association between advance directives and quality of end-of-life care: A national study. Journal of the American Geriatric Society, 55(2):189.
Johnson, S. (2018). How well do current measures assess the impact of advance care planning on concordance between patient preferences for end-of-life
care and the care received A methodological review. Journal of Pain and Symptom Management, 55(2).
Silvester, W., et al. (2016). Advance care planning in Australia: what does the law say? Australian Health Review. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/26567895
Molloy, D., et al. (2000). Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. JAMA, 283(11):1437.

23. History of
Advance
Directives
• Advance directives (AD) are a product of
the patient and consumer rights movements
of the 1960s and 1970s, when the US
Supreme Court established that patients
have a constitutional right to refuse
life-sustaining treatment—the right
of refusal
• The courts gradually decided that withdrawal
of care was morally equivalent to a patient’s
refusal and extended these rights to patients
without decisional capacity through their
healthcare surrogates

24. History of
Advance
Directives:
Patient
Self-
Determination
Act
• In 1990, Congress passed the Patient
Self-Determination Act (PSDA), incentivizing
healthcare entities to implement programs
that provide all adult patients, at the time
of admission or enrollment, with information
about their rights under state laws regarding
healthcare decision-making.
• As part of the PSDA, institutions must inform
patients of their right to:
– Participate in and direct their own
healthcare decisions
– Refuse medical or surgical treatment
– Prepare an advance directive
– Review information on the institutional
policies governing these rights
Omnibus Budget Reconciliation Act of 1990. (1990). Public Law No. 101-508, §4206 & 4751.

25. Legal Case:
Karen Ann
Quinlan
First case in US legal history – no PSDA
April 14, 1975
• 21-year-old Quinlan stopped breathing and
lapsed into a coma
5 months later – September 12, 1975
• Diagnosed as being in a persistent
vegetative state
• Parents requested to be disconnected
from ventilator
• Doctors and county prosecutor refused
to disconnect from machines; parents took
their daughter's case to court
10 years later – June 11, 1985
• Eventually weaned from respirator, Quinlan
survived nearly 10 more years
• She died of pulmonary failure in a nursing home

26. Legal Case:
Nancy Cruzan
Congress passed the Patient Self-Determination
Act (1990) in response to Cruzan’s case
January 11, 1983
• At 25 years old, Cruzan was in a car accident
in Missouri and was thrown from the car
• Paramedics resuscitated her
• A feeding tube was inserted after 3 weeks
in a coma
Almost 5 years later – October 23, 1987
• Cruzan’s parents requested that they be
allowed to remove feeding tube

27. Legal Case:
Nancy Cruzan
(cont.)
Almost 6 years later – 1988
• July 27 – Cruzan’s parents were authorized
to request the withholding of food and water
• November 16 – Missouri State Supreme Court
overturned the decision
• Appealed to the US Supreme Court
8 years later – December 26, 1990
• County court ruling allowed Cruzan’s parents
to remove the feeding tube
• Cruzan died 11 days later – 8 years after
her car accident

28. Legal Case:
Terri Schiavo
The case of Terri Schiavo became subject
of intense public debate and activism
February 25, 1990
• 26-year-old Terri collapsed at home and was
rushed to the hospital
• Four months later, Michael Schiavo, Terri’s
husband, was appointed her plenary guardian
8 years later – May 1998
• Michael Schiavo filed a petition to withdraw
life support
• Terri’s parents opposed, and court appointed
a new guardian ad litem (a third party during
custody disputes)

29. Legal Case:
Terri Schiavo
(cont.)
10-15 years later – 2000-2005
• 2000 - Given Schiavo's lack of a living will, a trial was
held to determine what Terri’s wishes would have been
• 2001 - Terri’s parents filed new evidence of Terri’s
wishes and claimed new medical treatments
were available
• 2003 - Feeding tube was removed for second time.
A week later, Florida legislature passed “Terri’s Law,”
ordering feeding tube to be reinserted
• 2004 - Florida Supreme Court overturned the law
as unconstitutional
• March 18, 2005 - Terri’s feeding tube was removed
for the third and final time
• March 31, 2005 - Terri died

30. What Are
Advance
Directives?
Advance directives are legal documents
that allow patients to formally state their
choices about what actions should be
taken or not taken regarding their
health in case they are no longer able
to make decisions for themselves
because of lack of capacity (inability
to communicate; lack of ability to
make informed medical decisions).

31. Advance
Directives
• ADs become legally valid as soon as
they are signed in front of the required
witnesses/notary
• They do not go into effect unless the patient
is unable to make his/her own decisions
• Each state has its own AD form
• Changes to an AD should be recorded and
given to appropriate clinicians and proxy
• Re-evaluate yearly and as needed
• Choosing not to have certain life-sustaining
or aggressive medical treatment is different
from refusing all medical care

32. Types of
Advance
Directives
• Most common types of advance directives:
– Living will
– Durable power of attorney for health
care/medical power of attorney
• State-specific; refer to HHS
• Provide a copy to the proxy, backup,
clinicians, and attorney
• Keep original safe but accessible
• Patient can carry a card stating that
they have an AD and where it is located

33. Living Will
• Specifies future healthcare decisions
when a patient with advanced illness
becomes unable to communicate their
wishes or make informed decisions
about their healthcare
• Describes the type of medical treatment
the person would want or would not want
• Identifies a legal representative (surrogate,
proxy) and provides general guidance
about what treatment an individual would
or would not want

34. Living Will
(cont.)
• Can range from general to specific wishes
• A legal document, not medical orders
• A competent person may revoke a
living will
• Can be changed or revoked at any
time if the patient is competent and
able to communicate
• More limited than durable power of
attorney for health Care (DPOA)/medical
power of attorney (MPOA)

35. Durable
Power of
Attorney for
Health Care
• The Durable Power of Attorney for Health Care
(DPOA) is a legal document in which a patient
names a person to be their proxy (agent) to
make all healthcare decisions if they become
unable to do so
• Usually part of an advance directive, but may
be separate, as can be broader than only
healthcare decisions
• The document may also be called a medical
power of attorney (MPOA)
• Proxy can be whomever the patient chooses
• Proxy should be someone the patient trusts
• Advisable to name a secondary proxy
Peeler, T. (2019). Types of advance medical directives. LegalMatch. Retrieved from: https://www.legalmatch.com/law-
library/article/types-of-advance-medical-directives.html

36. Durable
Power of
Attorney for
Health Care
(cont.)
• Proxy can speak with caregivers and make
decisions based on previous conversations
• If the patient’s wishes are unknown, the
proxy will decide based on what they
think the patient would want and their
assessment of the patient’s best interest
• Proxy cannot be a physician or nurse
providing professional care to the patient
(unless proxy is a close relative)
Peeler, T. (2019). Types of advance medical directives. LegalMatch. Retrieved from: https://www.legalmatch.com/law-
library/article/types-of-advance-medical-directives.html

37. Advance
Medical
Orders
• MOLST/POLST/MOST/POST
(Medical/Physician Orders for
Life-Sustaining Treatment)
• Out-of-Hospital Do Not Resuscitate
(OOH DNR)
• Used in conjunction with
advance directives
• State-specific
– https://polst.org/state-programs/
– Go to your state’s HHS website
– State determines which clinicians are
authorized to sign orders
• Patients should keep orders with them

38. POLST
MOLST
POST
MOST
Forms*
• The Physician/Medical Orders for
Life-Sustaining Treatment (POLST)
summarizes the patient’s wishes in the
form of medical orders that specify
specific medical treatments when
a patient has advanced illness
• The POLST is not an advance directive;
it is an actionable medical order that
becomes active upon signing,
regardless of patient’s cognitive status
• Can be used in emergency situations
*For continuity, these forms will be designated POLST for the remainder of the presentation
American College of Physicians. (2015). Advanced care planning implementation for practices. ACPOnline. Retrieved from:
https://www.acponline.org/system/files/documents/running_practice/payment_coding/medicare/advance_care_planning_toolkit.pdf

39. • In acute-care settings, patients are
generally full code unless otherwise
specified. If a full code patient stops
breathing or heart stops, CPR is initiated
• DNR order means a natural death will
be allowed to happen in case of arrest
• DNR does not indicate no treatment
• Some states and hospitals require a
new DNR order for each admission
• OOH DNR is used when a person does
not want to be resuscitated if they are
outside of a hospital
• Without a physician-signed OOH DNR order
or POLST, emergency crews perform CPR
Do-Not-
Resuscitate
(DNR)
Orders

40. • https://www.nhpco.org/advancedirective/
• https://www.nia.nih.gov/health/advance-
care-planning-health-care-directives
• https://polst.org/state-programs/
• https://fivewishes.org/#
Advance
Directives
Resources

41. Advance
Directives
and Orders
in Hospice
Care
• Patients are not required to have
advance directives or an OOH DNR
in order to receive hospice care
• Hospice staff will discuss the
importance of advance directives
in preserving patient choice
• Hospice can provide training on
ADs and difficult conversations

42. Starting the
Conversation
• Talking about EOL care can be difficult
• ACP is a recurring conversation
about the patient’s goals, values, and
treatment preferences; keep the
focus on the patient, not the
conversation facilitator
• Include MPOA in the ACP conversations
• When possible, schedule conversations
early in the disease process and
when the patient is mentally and
emotionally healthy
• Readily available tools and trainings
make difficult conversations easier

43. SPIKES
• Setting. Choose a private setting where you can
sit with the patient and a family member
or confidant. Plan ahead. Know the patient and situation.
• Perception. Ask the patient what they have been
told/understand before sharing information with them.
• Invitation. Ask permission to share your knowledge of the
situation. How much do they want to know about their
disease, tests, treatments, prognosis, etc.? Give permission
for them to stop or pause the conversation if needed.
• Knowledge. Share information clearly and compassionately.
Avoid jargon. Share information, then stop talking. Listen.
• Emotion/Empathy. Convey empathy with body language
and words. Allow for emotion, and offer support statements
(“I’m sorry we are having this conversation,” “It’s okay
to be upset.” Don’t say, “I understand what you’re
going through.”)
• Summary. Summarize the conversation. Plan for next
visit/conversation.
Buckman, R., et al. (1992). How to break bad news: A guide for health care professionals.
Baltimore: The Johns Hopkins University Press

44. REMAP
• Reframe – Current decision was made in context
– Assess patient/family perception and understanding.
“What is your understanding of…?”
– Reframe statement/question. “Given the
circumstances, is it okay if we talk about next steps?”
• Expect emotion – Do not ignore feelings/emotional reactions
– Observe emotions. Acknowledge them.
“I cannot imagine what you are feeling right now.”
Allow for silence.
• Map out the future – Do not rush to this step
– Identify the patient’s goals; doing so can help
determine appropriate care/treatment course in
next step.
– Ask about what situations would be unacceptable
(e.g., intubation, nursing home, dialysis, etc.)
• Align with values – Repeat or rephrase patient’s/caregiver’s
values and goals
• Plan treatments/care that matches values – “Given that
you would like to…options for treatment include…”

45. Physician Reimbursement
for Advance Care Planning

46. ACP Services
Reimbursement
CPT Code 99497
• Advance care planning, including the
explanation and discussion of advance
directives such as standard forms
(with completion of such forms, when
performed) by the physician or other
qualified healthcare professional
• First 30 minutes of the day, face-to-face
with the patient, family member(s),
and/or surrogate
CPT Code 99498
• Each additional 30 minutes (list separately
in addition to code for primary procedure)
• May have multiple conversations in a day

47. Closing Thought
“I have an advance directive, not because
I have a serious illness, but because
I have a family.”
—Ira Byock, MD

48. Questions?

49. References
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