Medical Ethics 

Highlights

Patients Near     the End of Life Advance Care     Planning Problems of     Life-Sustaining     Treatments

Advance Care Planning

Advance care planning allows a competent person to indicate preferences for care or choose a surrogate in the event that the patient cannot make health care decisions. It allows the patient's values and circumstances to shape the plan and allows specific arrangements to be made to ensure implementation of the plan.

Physicians should routinely raise the issue of advance planning with competent adult patients during outpatient visits and encourage them to discuss their values and preferences with their surrogates and family members. These discussions let the physician know the patient's views, enable the physician to update the medical record and allow the physician to reassure patients that he or she is willing to discuss these sensitive issues and will respect their choices. The patient and the physician should negotiate plans to make sure patient wishes are implemented. Discussions about patient preferences should be documented in the medical record. Advance planning takes place in conversations with the physician (with documentation in the medical record) or through written advance directives, such as a living will or durable power of attorney for health care. The latter enables a patient to appoint a surrogate who will make decisions if the patient becomes unable to do so. The surrogate is required to act in accordance with the patient's previously expressed preferences or best interests. Living wills enable persons to describe the kind of treatment they would like to receive in the event that they lose decision-making capacity. Uncertainty about a future clinical course complicates the interpretation of living wills and emphasizes the need for physicians and patients to discuss patient preferences before a crisis arises.

Talking about future medical care is an effective method of planning. The primary care physician and other key heath care personnel should have a written advance directive in the patient's medical record. When there is no advance directive and the patient's values and preferences are unknown or unclear, decisions should be based on the patient's best interests whenever possible, as interpreted by a guardian or by a person with loving knowledge of the patient. When making the decision to forgo treatment, many people give the most weight to reversibility of disease or dependence on life support, loss of capacity for social interaction or nearness to death.