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Advance Directives and Advance Care Planning
Ensuring Patient Voices Are Heard
CME Provider Information
Satisfactory Completion
Learners must complete an evaluation form to receive a certificate of completion. You must participate
in the entire activity as partial credit is not available. If you are seeking continuing education credit for a
specialty not listed below, it is your responsibility to contact your licensing/certification board to determine
course eligibility for your licensing/certification requirement.
Physicians
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and
VITAS®
Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation Council for
Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and
the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA
Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
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: 06/06/2021 – 06/06/2024.
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 01/31/2023.
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
To educate healthcare professionals (HCP)
about the history and importance of advance
care planning (ACP) and advance directives
(AD), and provide resources for HCPs to engage
in ACP and completing ADs with their patients
Goal
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
What Is ACP?
National Hospice & Palliative Care Organization (NHPCO). Advance Care Planning. Retrieved from:
https://www.caringinfo.org/planning/advance-directives/
Per the National Hospice and Palliative Care Organization (NHPCO):
“Advance care planning is a process, not an
event, and is planning for future care based
on a person’s values, beliefs, preferences, and
specific medical issues. An advance directive
is the record of that process.”
What Is ACP?
Communication and Support:
• Conversations among patients,
their loved ones, and their healthcare
team—with consideration of the
patient’s relationships, culture,
and health—to explore treatment
options and make decisions
about care preferences
• Frequent and ongoing conversations
about values, goals, and preferences
• Help people at any age or stage
of health understand and share
their values, goals, and
preferences regarding
future care
• Most commonly about end-of-life
(EOL) decisions
• These decisions can then be
recorded in an advance
directive (AD)
Why Is ACP Important?
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). 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.
• “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.
• About 70% of Americans would prefer
to die at home, but they also don’t want
to be a burden to their loved ones.
• About one-third of US patients die
at home.
ACP Statistics
Aaron, S. et al. (2022). Understanding factors that predict advance directive completion. Palliative Medicine Reports, 3(3): 220-224.
Ping, Y. (2021). Changes in advance care planning for nursing home residents during the COVID-19 pandemic. JAMDA. 22(209-214).
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.
In a 2017 review:
• 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 to complete AD
than younger adults (45.6%
vs. 31.6%)
In a 2020 study including patients
with advanced cancer:
• White population up to 2x
more likely to complete
AD than average
• Completion of AD increases
as age increases
VITAS-sponsored Ipsos survey of 1,000 Americans, March 2022.
A 2022 VITAS survey identified key benchmarks for triggering ACP conversations:
46%
“When you are old enough
to make your own
healthcare decisions”
34.5%
“When you hit a
certain age” (50s)
27.2%
said the pandemic
has increased their
thoughts around ACP
71.4%
said they haven’t been
approached by a healthcare
professional about ACP
When Should ACP Discussions Start?
Somewhat…
Not too/not
at all…
Extremely
important, 51%
Very important,
38%
ACP Challenges
Aaron, S., et al. (2022). Understanding factors that predict advance directive completion. Palliative Medicine Reports, 3(3): 220-224
Fulmer, T., et al. (2018). Physicians' views on ACP and end-of-life conversations .Journal of the American Geriatrics Society, 66(6):1201-1205.
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).
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.JPSM, 55(2).
Macedo, J. (2023). Perceptions, attitudes, and knowledge toward advance directives: a scoping review. Healthcare, 11(20): 2755.
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
Lack of understanding of ACP
• Lack of understanding of
illness/prognosis
• Poor healthcare literacy
• Difficult topic to bring up
– Increased during COVID,
but did not continue
• Lack of time (physicians)
• Lack of concordance with
wishes and care provided
• Lack of system support
Figure 1. Responses to question:
In your own opinion, how important
is it that healthcare providers have
advance care planning conversations
with patients?
Physician views on ACP
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)
EOL Discussions Align Care with Patients’ Wishes and Values
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.
7.3
6.5
7.3
7.4
7 7.2
0
2
4
6
8
10
Depressed Nervous or worried Sad
McGill Psychological Subscale
With ACP Without ACP
52.9%
48.8%
63.0%
71.7%
28.7% 27.8% 28.5%
46.1%
20
40
60
80
100
Accepts illness is
terminal
Against death in ICU Completed DNR
order
Completed living
will, durable power
of attorney, or
healthcare proxy
Acceptance, Preferences
With ACP Without ACP
*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
ACP Outcomes
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).
Mirachi, F. (2020). TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end-of-life – the realistic interpretation of
advance directives. Journal of Healthcare Risk Management, 41(1): 22-30.
Modes, M. (2020). Patient-reported receipt of goal-concordant care among seriously ill outpatients – prevalence and associated factors. Journal of Pain and Symptom Management, 60(4): 765-773.
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.
• ACP conversations can 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 among
patients and their loved ones
• In a 2020 study, 60% of seriously
ill patients felt they received
goal-concordant care
• A 2017 review study found that
concordant care at EOL ranged
from 14% to 98%
• A 2020 study of simulated patient
experience revealed that nurses
and resident physicians provided
goal-concordant care for patients
27-53% of the time.
ACP Opportunities
Liu, W., et al. (2020). Improved quality of death and dying in care homes: Palliative care stepped wedge randomized control trial in Australia. JAGS: 68:305-312.
Lum, H., et al. (2020) Effectiveness of advance care planning group visits among older adults in primary care. JAGS. 68(10): 2382-2389.
Patel, M., et al. (2021). Health care coach to assist with advance care planning and symptom management 1 A randomized controlled trial. Contemporary Clinical Trials: 111, 106617.
• Educating and training HCP
– Interdisciplinary
and ongoing
– How to have difficult
conversations
• Public outreach
– Trust of healthcare
– Healthcare literacy
– Understanding of illness
• Models
– Dedicated team
– Palliative care:
in-home, in clinic
– ACP group visits
(26% increase in AD)
– Palliative Care
Needs Rounds
– Nurse-led
multidisciplinary team
– Health care coaches
(non-medical)
• Systems
– At-risk groups
– Primary care
– Long term care
facilities, care homes
• Resources on slide 29
History of Advance Directives
Omnibus Budget Reconciliation Act of 1990. (1990). Public Law No. 101-508, §4206 & 4751.
• Advance directives 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
• In 1990, Congress passed the Patient
Self-Determination Act (PSDA), incentivizing
healthcare entities to provide all adult patients,
at the time of admission or enrollment,
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
Legal Case: Karen Ann Quinlan- Prolonging Suffering
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
First case in US
legal history –
no PSDA
Legal Case: Nancy Cruzan- Patient Self-Determination Act
January 11, 1983
25-year-old Nancy
Cruzan was in
a car accident
in Missouri and
resuscitated by
paramedics
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
Almost 6 years later
1988
July 27
Cruzan’s parents
authorized request the
withholding
of food and water
November 16
Overturned by
the Missouri State
Supreme Court –
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
As a result,
Congress passed
the PSDA in 1990
Legal Case: Terri Schiavo- Importance of Advance Directives
February 25, 1990
26 year-old
Terri Schiavo
collapsed
and was
hospitalized
Four months later,
Terri’s husband
Michael Schiavo
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
2000
Given the lack of a
living will, a trial
was held to
determine
Terri’s wishes
The court found
that Terri was in a
persistent vegetative
state and had made
statements that she
would have wanted
the feeding tube
removed
Legal Case: Terri Schiavo (cont.)
2001
Feeding tube
removed April 24,
reinserted April 26.
Terri’s parents
unsuccessfully
challenged PVS
diagnosis
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
Terri’s Law as
unconstitutional
March 18, 2005
Terri’s feeding
tube was removed
for the third and
final time
March 31, 2005
Terri died,
15 years after
her collapse
What Are Advance Directives?
• Advance directives (AD) 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 make or
communicate informed medical decisions).
Advance Directives
• Most common types of advance directives:
– Living will
– Durable power of attorney
for healthcare/medical
power of attorney
• State-specific; refer to your state’s
Health and Human Services
(HHS) website
• Legally valid when signed, but in
effect/activated only when the
patient is unable to make their
own decisions
• Record keeping:
– Keep original safe but accessible
(pocket cards available)
– Provide a copy to the proxy,
backup, clinicians, and attorney
– Reevaluate yearly and as needed,
share updates to appropriate people
• Choosing not to have certain life-saving
or sustaining medical treatment is
different from refusing all medical care
Living Will
• Specifies future healthcare decisions when a patient with
incurable illness lacks capacity for healthcare decisions
• Legal document (not medical order) which
– Identifies a legal representative (surrogate, proxy);
and Describes type of medical treatment the person
would want or would not want (can be general
or specific)
• A competent person can revoke or change their living will
• Choose someone trustworthy as surrogate decision-maker
Durable Power of Attorney for HealthCare
Peeler, T. (2019). Types of advance medical directives. LegalMatch. Retrieved from: https://www.legalmatch.com/law-library/article/types-of-advance-medical-directives.html
Walter, K. (2020). Durable power of attorney for health care. JAMA. 2021; 326(16):1642. doi:10.1001/jama.2021.15882
• The Durable Power of Attorney for
HealthCare (DPOA/MPOA) is a legal
document in which a patient names
a person to be their proxy to make
healthcare decisions if they become
unable to do so
• Usually part of a more
comprehensive AD
• Proxy can make decisions
with input from others
• If the patient’s wishes are unknown,
the agent/proxy will make decisions
based on what they think the patient
would want and in the patient’s
best interests
• HCP professional providing care to
the patient cannot be a proxy unless
they are a close relative to the patient
• Some states restrict a proxy’s authority;
refer to your state’s HHS website
Also known as medical power of attorney (MPOA)
Advance Medical Orders
• Medical/Physician Orders for
Life-Sustaining Treatment
• Often includes Out-of-Hospital
Do Not Resuscitate (OOH DNR)
• Summarizes the patient’s wishes
in the form of medical orders that
specify specific medical treatments
when a patient has advanced illness
• Activated upon signing, regardless
of patient’s cognitive status
• Often used in conjunction
with legal advance directives
• Can be used in emergency
situations
• State-specific forms
• Each state determines appropriate
clinicians to sign orders;
see resources page
• Patients should keep
orders with them
MOLST | POLST | MOST | POST
POLST
Do-Not-Resuscitate (DNR) Orders
• In acute-care settings, default is
full code. 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; resuscitation will not be initiated
• 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 signed OOH DNR order
or POLST, emergency crews
perform CPR
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
• With an emphasis on preserving
patient choice (autonomy), hospice
staff will discuss code status and
the importance of advance directives
• Hospice can provide training on
ADs and difficult conversations
Advance Care Planning Resources
• https://www.fivewishes.org/
• https://theconversationproject.org/
• https://www.vitas.com/hospice-and-
palliative-care-basics/end-of-life-
care-planning
• https://www.caringinfo.org/planning/
advance-directives/creating-advance-
directive/
• https://www.nia.nih.gov/health/advance-
care-planning-health-care-directives
• https://deathcafe.com/
• https://deathoverdinner.org/
• https://deathoverdimsum.org/
• https://polst.org/
• https://www.hhs.gov/aging/long-term-
care/index.html
• https://www.vitas.com/for-healthcare-
professionals/education-and-training/
talking-to-your-patients-about-end-of-life
• VITAS Goals of Care Preceptorship
(reach out to local VITAS)
SPIKES
Buckman, R., et al. (1992). How to break bad news: A guide for health care professionals.
Baltimore: The Johns Hopkins University Press
REMAP
Reframe. Decision-making in context
of current circumstances:
• Assess patient/family perception and
understanding. “What is your
understanding of…?”
• Reframe statement/question. “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; 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…”
Start the Conversation
• These conversations can be difficult
• ACP is an ongoing conversation
about the patient’s goals, values,
and treatment preferences
• Conversations may be 5 minutes,
or they may be 50 minutes
• Include MPOA (and others) in ACP
conversations as patient allows/requests
• When possible, begin conversations
early in the disease process
• Readily available tools and trainings
make difficult conversations easier
• Take the initiative to start the conversation
• Keep the focus on the patient
• Listen more than you talk
• Allow for uncomfortable silence
• Find out what is important to the patient
• Allow the patients to make decisions
based on their values, not yours
• It’s okay to not know all the answers –
for yourself, the patient, the family
• Talk about faith, if it’s important
• Be honest and compassionate
Physician and Practitioner Billing Reference
Billing when Patient enrolled in Hospice
Modifier Description Modifier Description
GV • Attending physician/NP not employed/
not paid under agreement by the
patient’s hospice provider
• Services are related to patient’s
terminal condition or not paid under
agreement by hospice provider
GW • Service not related to the hospice
patient’s terminal condition
• Submitted to Medicare Part A
Billing for Advance Care Planning
Discussion with patient and/or proxy by physician or other qualified HCP (NP, PA)
Patient must be present
Must specify consent to ACP, time spent, document discussion and any decisions
Regardless of patient location; can be performed via telehealth
CPT code 99497 CPT code 99498
• First 30 minutes of ACP per day (≥16 minutes) • Each additional 30 minutes of ACP per day
(≥ 16 min)
• May have multiple 99498 codes in a day
Closing Thought
“Our ultimate goal, after all,
is not a good death,
but a good life to the very end.”
—Atul Gawande, Being Mortal
Questions?
Additional Hospice Resources
The VITAS mobile app includes helpful
tools and information:
• Interactive Palliative Performance
Scale (PPS)
• Body-Mass Index (BMI) calculator
• Opioid converter
• Disease-specific hospice
eligibility guidelines
• Hospice care discussion guides
We look forward to having you attend
some of our future webinars!
36
Scan now to
download the
VITAS app.
References
Aaron, S., et al. (2022). Understanding factors that predict advance directive completion. Palliative Medicine Reports, 3(3): 220-224
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
Buckman, R., et al. (1992). How to break bad news: A guide for health care professionals. Baltimore: The Johns Hopkins
University Press.
Cross, S., & Warraich, H. (2019). Changes in the place of death in the United States. NEJM, 381: 2369-2370.
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
Eggerston, L. (2013). Doctors, patients urged to discuss advanced care plans. CMAJ, 185(13): E617–E618.
Fulmer, T., et al. (2018). Physicians’ views on ACP and end-of-life conversations. Journal of the American Geriatric Society,
66(6):1201-1205.
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).
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).
References
Henage, C. (2020). Educational interventions to improve advance care planning discussions, documentation
and billing. American Journal of Hospice & Palliative Medicine, 38(4) 355-360.
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.
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).
Liu, W., et al. (2019). Improved quality of death and dying in care homes: A palliative care stepped wedge
randomized control trial in Australia. JAGS. 68:305-312.
Lum, H., et al. (2020) Effectiveness of advance care planning group visits among older adults in primary care.
JAGS. 68(10): 2382-2389.
Macedo, J. (2023). Perceptions, attitudes, and knowledge toward advance directives: a scoping review.
Healthcare, 11(20): 2755.
Mirachi, F., et al. (2020). TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal
concordant care when critically ill or at end-of-life – the realistic interpretation of advance directives. Journal of
“Healthcare Risk Management, 41(1): 22-30.
References
Modes, M., et al. (2020). Patient-reported receipt of goal-concordant care among seriously ill outpatients – prevalence
and associated factors. Journal of Pain and Symptom Management, 60(4): 765-773.
Molloy, D., et al. (2000). Systematic implementation of an advance directive program in nursing homes: A randomized
controlled trial. JAMA, 283(11):1437.
National Hospice & Palliative Care Organization. Advance Directives. https://www.caringinfo.org/planning/advance-
directives/
Nouri, S., et al. (2021). The PREPARE for your care program increases advance care planning engagement among
diverse older adults with cancer. Cancer, 127(19): 3631-3639.
Olaisen, R. H. (2020). QuickStats: Percentage of Deaths, by Place of Death—National Vital Statistics System,
United States, 2000–2018.
Omnibus Budget Reconciliation Act of 1990. (1990). Public Law No. 101-508, §4206 & 4751.
Patel, M., et al. (2022). Effect of a community health worker intervention on acute care use, advance care planning,
and patient-reported outcomes among adults with advanced stages of cancer. JAMA Oncology, 8(8), 1139–1148.
Patel, M., et al. (2021). Health care coach to assist with advance care planning and symptom management:
A randomized controlled trial. Contemporary Clinical Trials: 111, 106617.
References
Peeler, T. (2019). Types of advance medical directives. LegalMatch. Retrieved from: https://www.legalmatch.com/law-library/article/
types-of-advance-medical-directives.html
Ping, Y. (2021). Changes in advance care planning for nursing home residents during the COVID-19 pandemic. JAMDA. 22(209-214).
Silveira, M., et al. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of
Medicine, 362:1211-1218.
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
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.
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
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.
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.

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Advance Directives and Advance Care Planning: Ensuring Patient Voices Are Heard

  • 1. Advance Directives and Advance Care Planning Ensuring Patient Voices Are Heard
  • 2. CME Provider Information Satisfactory Completion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 2
  • 3. 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: 06/06/2021 – 06/06/2024. 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 01/31/2023. 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
  • 4. To educate healthcare professionals (HCP) about the history and importance of advance care planning (ACP) and advance directives (AD), and provide resources for HCPs to engage in ACP and completing ADs with their patients Goal
  • 5. 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
  • 6. What Is ACP? National Hospice & Palliative Care Organization (NHPCO). Advance Care Planning. Retrieved from: https://www.caringinfo.org/planning/advance-directives/ Per the National Hospice and Palliative Care Organization (NHPCO): “Advance care planning is a process, not an event, and is planning for future care based on a person’s values, beliefs, preferences, and specific medical issues. An advance directive is the record of that process.”
  • 7. What Is ACP? Communication and Support: • Conversations among patients, their loved ones, and their healthcare team—with consideration of the patient’s relationships, culture, and health—to explore treatment options and make decisions about care preferences • Frequent and ongoing conversations about values, goals, and preferences • Help people at any age or stage of health understand and share their values, goals, and preferences regarding future care • Most commonly about end-of-life (EOL) decisions • These decisions can then be recorded in an advance directive (AD)
  • 8. Why Is ACP Important? 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). 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. • “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. • About 70% of Americans would prefer to die at home, but they also don’t want to be a burden to their loved ones. • About one-third of US patients die at home.
  • 9. ACP Statistics Aaron, S. et al. (2022). Understanding factors that predict advance directive completion. Palliative Medicine Reports, 3(3): 220-224. Ping, Y. (2021). Changes in advance care planning for nursing home residents during the COVID-19 pandemic. JAMDA. 22(209-214). 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. In a 2017 review: • 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 to complete AD than younger adults (45.6% vs. 31.6%) In a 2020 study including patients with advanced cancer: • White population up to 2x more likely to complete AD than average • Completion of AD increases as age increases
  • 10. VITAS-sponsored Ipsos survey of 1,000 Americans, March 2022. A 2022 VITAS survey identified key benchmarks for triggering ACP conversations: 46% “When you are old enough to make your own healthcare decisions” 34.5% “When you hit a certain age” (50s) 27.2% said the pandemic has increased their thoughts around ACP 71.4% said they haven’t been approached by a healthcare professional about ACP When Should ACP Discussions Start?
  • 11. Somewhat… Not too/not at all… Extremely important, 51% Very important, 38% ACP Challenges Aaron, S., et al. (2022). Understanding factors that predict advance directive completion. Palliative Medicine Reports, 3(3): 220-224 Fulmer, T., et al. (2018). Physicians' views on ACP and end-of-life conversations .Journal of the American Geriatrics Society, 66(6):1201-1205. 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). 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.JPSM, 55(2). Macedo, J. (2023). Perceptions, attitudes, and knowledge toward advance directives: a scoping review. Healthcare, 11(20): 2755. 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 Lack of understanding of ACP • Lack of understanding of illness/prognosis • Poor healthcare literacy • Difficult topic to bring up – Increased during COVID, but did not continue • Lack of time (physicians) • Lack of concordance with wishes and care provided • Lack of system support Figure 1. Responses to question: In your own opinion, how important is it that healthcare providers have advance care planning conversations with patients? Physician views on ACP
  • 12. 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)
  • 13. EOL Discussions Align Care with Patients’ Wishes and Values 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. 7.3 6.5 7.3 7.4 7 7.2 0 2 4 6 8 10 Depressed Nervous or worried Sad McGill Psychological Subscale With ACP Without ACP 52.9% 48.8% 63.0% 71.7% 28.7% 27.8% 28.5% 46.1% 20 40 60 80 100 Accepts illness is terminal Against death in ICU Completed DNR order Completed living will, durable power of attorney, or healthcare proxy Acceptance, Preferences With ACP Without ACP *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
  • 14. ACP Outcomes 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). Mirachi, F. (2020). TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end-of-life – the realistic interpretation of advance directives. Journal of Healthcare Risk Management, 41(1): 22-30. Modes, M. (2020). Patient-reported receipt of goal-concordant care among seriously ill outpatients – prevalence and associated factors. Journal of Pain and Symptom Management, 60(4): 765-773. 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. • ACP conversations can 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 among patients and their loved ones • In a 2020 study, 60% of seriously ill patients felt they received goal-concordant care • A 2017 review study found that concordant care at EOL ranged from 14% to 98% • A 2020 study of simulated patient experience revealed that nurses and resident physicians provided goal-concordant care for patients 27-53% of the time.
  • 15. ACP Opportunities Liu, W., et al. (2020). Improved quality of death and dying in care homes: Palliative care stepped wedge randomized control trial in Australia. JAGS: 68:305-312. Lum, H., et al. (2020) Effectiveness of advance care planning group visits among older adults in primary care. JAGS. 68(10): 2382-2389. Patel, M., et al. (2021). Health care coach to assist with advance care planning and symptom management 1 A randomized controlled trial. Contemporary Clinical Trials: 111, 106617. • Educating and training HCP – Interdisciplinary and ongoing – How to have difficult conversations • Public outreach – Trust of healthcare – Healthcare literacy – Understanding of illness • Models – Dedicated team – Palliative care: in-home, in clinic – ACP group visits (26% increase in AD) – Palliative Care Needs Rounds – Nurse-led multidisciplinary team – Health care coaches (non-medical) • Systems – At-risk groups – Primary care – Long term care facilities, care homes • Resources on slide 29
  • 16. History of Advance Directives Omnibus Budget Reconciliation Act of 1990. (1990). Public Law No. 101-508, §4206 & 4751. • Advance directives 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 • In 1990, Congress passed the Patient Self-Determination Act (PSDA), incentivizing healthcare entities to provide all adult patients, at the time of admission or enrollment, 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
  • 17. Legal Case: Karen Ann Quinlan- Prolonging Suffering 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 First case in US legal history – no PSDA
  • 18. Legal Case: Nancy Cruzan- Patient Self-Determination Act January 11, 1983 25-year-old Nancy Cruzan was in a car accident in Missouri and resuscitated by paramedics 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 Almost 6 years later 1988 July 27 Cruzan’s parents authorized request the withholding of food and water November 16 Overturned by the Missouri State Supreme Court – 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 As a result, Congress passed the PSDA in 1990
  • 19. Legal Case: Terri Schiavo- Importance of Advance Directives February 25, 1990 26 year-old Terri Schiavo collapsed and was hospitalized Four months later, Terri’s husband Michael Schiavo 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 2000 Given the lack of a living will, a trial was held to determine Terri’s wishes The court found that Terri was in a persistent vegetative state and had made statements that she would have wanted the feeding tube removed
  • 20. Legal Case: Terri Schiavo (cont.) 2001 Feeding tube removed April 24, reinserted April 26. Terri’s parents unsuccessfully challenged PVS diagnosis 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 Terri’s Law as unconstitutional March 18, 2005 Terri’s feeding tube was removed for the third and final time March 31, 2005 Terri died, 15 years after her collapse
  • 21. What Are Advance Directives? • Advance directives (AD) 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 make or communicate informed medical decisions).
  • 22. Advance Directives • Most common types of advance directives: – Living will – Durable power of attorney for healthcare/medical power of attorney • State-specific; refer to your state’s Health and Human Services (HHS) website • Legally valid when signed, but in effect/activated only when the patient is unable to make their own decisions • Record keeping: – Keep original safe but accessible (pocket cards available) – Provide a copy to the proxy, backup, clinicians, and attorney – Reevaluate yearly and as needed, share updates to appropriate people • Choosing not to have certain life-saving or sustaining medical treatment is different from refusing all medical care
  • 23. Living Will • Specifies future healthcare decisions when a patient with incurable illness lacks capacity for healthcare decisions • Legal document (not medical order) which – Identifies a legal representative (surrogate, proxy); and Describes type of medical treatment the person would want or would not want (can be general or specific) • A competent person can revoke or change their living will • Choose someone trustworthy as surrogate decision-maker
  • 24. Durable Power of Attorney for HealthCare Peeler, T. (2019). Types of advance medical directives. LegalMatch. Retrieved from: https://www.legalmatch.com/law-library/article/types-of-advance-medical-directives.html Walter, K. (2020). Durable power of attorney for health care. JAMA. 2021; 326(16):1642. doi:10.1001/jama.2021.15882 • The Durable Power of Attorney for HealthCare (DPOA/MPOA) is a legal document in which a patient names a person to be their proxy to make healthcare decisions if they become unable to do so • Usually part of a more comprehensive AD • Proxy can make decisions with input from others • If the patient’s wishes are unknown, the agent/proxy will make decisions based on what they think the patient would want and in the patient’s best interests • HCP professional providing care to the patient cannot be a proxy unless they are a close relative to the patient • Some states restrict a proxy’s authority; refer to your state’s HHS website Also known as medical power of attorney (MPOA)
  • 25. Advance Medical Orders • Medical/Physician Orders for Life-Sustaining Treatment • Often includes Out-of-Hospital Do Not Resuscitate (OOH DNR) • Summarizes the patient’s wishes in the form of medical orders that specify specific medical treatments when a patient has advanced illness • Activated upon signing, regardless of patient’s cognitive status • Often used in conjunction with legal advance directives • Can be used in emergency situations • State-specific forms • Each state determines appropriate clinicians to sign orders; see resources page • Patients should keep orders with them MOLST | POLST | MOST | POST
  • 26. POLST
  • 27. Do-Not-Resuscitate (DNR) Orders • In acute-care settings, default is full code. 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; resuscitation will not be initiated • 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 signed OOH DNR order or POLST, emergency crews perform CPR
  • 28. 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 • With an emphasis on preserving patient choice (autonomy), hospice staff will discuss code status and the importance of advance directives • Hospice can provide training on ADs and difficult conversations
  • 29. Advance Care Planning Resources • https://www.fivewishes.org/ • https://theconversationproject.org/ • https://www.vitas.com/hospice-and- palliative-care-basics/end-of-life- care-planning • https://www.caringinfo.org/planning/ advance-directives/creating-advance- directive/ • https://www.nia.nih.gov/health/advance- care-planning-health-care-directives • https://deathcafe.com/ • https://deathoverdinner.org/ • https://deathoverdimsum.org/ • https://polst.org/ • https://www.hhs.gov/aging/long-term- care/index.html • https://www.vitas.com/for-healthcare- professionals/education-and-training/ talking-to-your-patients-about-end-of-life • VITAS Goals of Care Preceptorship (reach out to local VITAS)
  • 30. SPIKES Buckman, R., et al. (1992). How to break bad news: A guide for health care professionals. Baltimore: The Johns Hopkins University Press
  • 31. REMAP Reframe. Decision-making in context of current circumstances: • Assess patient/family perception and understanding. “What is your understanding of…?” • Reframe statement/question. “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; 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…”
  • 32. Start the Conversation • These conversations can be difficult • ACP is an ongoing conversation about the patient’s goals, values, and treatment preferences • Conversations may be 5 minutes, or they may be 50 minutes • Include MPOA (and others) in ACP conversations as patient allows/requests • When possible, begin conversations early in the disease process • Readily available tools and trainings make difficult conversations easier • Take the initiative to start the conversation • Keep the focus on the patient • Listen more than you talk • Allow for uncomfortable silence • Find out what is important to the patient • Allow the patients to make decisions based on their values, not yours • It’s okay to not know all the answers – for yourself, the patient, the family • Talk about faith, if it’s important • Be honest and compassionate
  • 33. Physician and Practitioner Billing Reference Billing when Patient enrolled in Hospice Modifier Description Modifier Description GV • Attending physician/NP not employed/ not paid under agreement by the patient’s hospice provider • Services are related to patient’s terminal condition or not paid under agreement by hospice provider GW • Service not related to the hospice patient’s terminal condition • Submitted to Medicare Part A Billing for Advance Care Planning Discussion with patient and/or proxy by physician or other qualified HCP (NP, PA) Patient must be present Must specify consent to ACP, time spent, document discussion and any decisions Regardless of patient location; can be performed via telehealth CPT code 99497 CPT code 99498 • First 30 minutes of ACP per day (≥16 minutes) • Each additional 30 minutes of ACP per day (≥ 16 min) • May have multiple 99498 codes in a day
  • 34. Closing Thought “Our ultimate goal, after all, is not a good death, but a good life to the very end.” —Atul Gawande, Being Mortal
  • 36. Additional Hospice Resources The VITAS mobile app includes helpful tools and information: • Interactive Palliative Performance Scale (PPS) • Body-Mass Index (BMI) calculator • Opioid converter • Disease-specific hospice eligibility guidelines • Hospice care discussion guides We look forward to having you attend some of our future webinars! 36 Scan now to download the VITAS app.
  • 37. References Aaron, S., et al. (2022). Understanding factors that predict advance directive completion. Palliative Medicine Reports, 3(3): 220-224 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 Buckman, R., et al. (1992). How to break bad news: A guide for health care professionals. Baltimore: The Johns Hopkins University Press. Cross, S., & Warraich, H. (2019). Changes in the place of death in the United States. NEJM, 381: 2369-2370. 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 Eggerston, L. (2013). Doctors, patients urged to discuss advanced care plans. CMAJ, 185(13): E617–E618. Fulmer, T., et al. (2018). Physicians’ views on ACP and end-of-life conversations. Journal of the American Geriatric Society, 66(6):1201-1205. 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). 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).
  • 38. References Henage, C. (2020). Educational interventions to improve advance care planning discussions, documentation and billing. American Journal of Hospice & Palliative Medicine, 38(4) 355-360. 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. 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). Liu, W., et al. (2019). Improved quality of death and dying in care homes: A palliative care stepped wedge randomized control trial in Australia. JAGS. 68:305-312. Lum, H., et al. (2020) Effectiveness of advance care planning group visits among older adults in primary care. JAGS. 68(10): 2382-2389. Macedo, J. (2023). Perceptions, attitudes, and knowledge toward advance directives: a scoping review. Healthcare, 11(20): 2755. Mirachi, F., et al. (2020). TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end-of-life – the realistic interpretation of advance directives. Journal of “Healthcare Risk Management, 41(1): 22-30.
  • 39. References Modes, M., et al. (2020). Patient-reported receipt of goal-concordant care among seriously ill outpatients – prevalence and associated factors. Journal of Pain and Symptom Management, 60(4): 765-773. Molloy, D., et al. (2000). Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. JAMA, 283(11):1437. National Hospice & Palliative Care Organization. Advance Directives. https://www.caringinfo.org/planning/advance- directives/ Nouri, S., et al. (2021). The PREPARE for your care program increases advance care planning engagement among diverse older adults with cancer. Cancer, 127(19): 3631-3639. Olaisen, R. H. (2020). QuickStats: Percentage of Deaths, by Place of Death—National Vital Statistics System, United States, 2000–2018. Omnibus Budget Reconciliation Act of 1990. (1990). Public Law No. 101-508, §4206 & 4751. Patel, M., et al. (2022). Effect of a community health worker intervention on acute care use, advance care planning, and patient-reported outcomes among adults with advanced stages of cancer. JAMA Oncology, 8(8), 1139–1148. Patel, M., et al. (2021). Health care coach to assist with advance care planning and symptom management: A randomized controlled trial. Contemporary Clinical Trials: 111, 106617.
  • 40. References Peeler, T. (2019). Types of advance medical directives. LegalMatch. Retrieved from: https://www.legalmatch.com/law-library/article/ types-of-advance-medical-directives.html Ping, Y. (2021). Changes in advance care planning for nursing home residents during the COVID-19 pandemic. JAMDA. 22(209-214). Silveira, M., et al. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362:1211-1218. 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 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. 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 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. 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.