Controversy in Advance Care Planning Quality Improvement
Perhaps you’ve heard the controversy over Advance Care Planning as a quality metric. In October 2021, prominent researchers in ACP wrote a viewpoint in JAMA called “What’s Wrong with Advance Care Planning?” (Morrison RS, Meier DE, Arnold RM. What’s Wrong With Advance Care Planning? JAMA. 2021;326(16):1575–1576. doi:10.1001/jama.2021.16430). The article highlights the lack of evidence to support that ACP improves end of life care, such as being associated with goal-concordant care or quality of life. The article defines ACP as advance documentation that informs later discussions when patients lack capacity (such as an advance directive), which may be based on hypothetical scenarios. The authors distinguish this from what they refer to as “in the moment” decision-making, such as when patients with serious illness and their families discuss goals and treatment decisions, and from documentation designating a surrogate. The authors delineate the complex steps needed to connect a patient’s advance wishes to actual decision-making and reflect on the complexity and emotional weight of treatment decisions near the end of life. The authors advocate against prioritizing ACP QI metrics, especially in patients who are healthy, and recommend directing efforts elsewhere, such as towards supporting patients and surrogates in difficult in-the-moment decision-making.
Where does this leave our efforts at improvement ACP in DHM? As we reflect on the thought-provoking points raised in the article, we should distinguish our ACP efforts from what is referenced in the article. Since our metric focuses on hospitalized patients 75 or older or with serious illness, the values, wishes, and treatment preferences discussed with these patients are relevant to the patient’s current illness and projected illness trajectory, rather than based on more theoretical concerns. We also include in ACP the documentation of a patient’s surrogate, values, hopes, fears, what gives their life meaning, and other important personal information, which can help to amplify the patient’s voice in their treatment decisions as well as allow providers to better align their care and treatment with the patient’s goals and values. Our overall take-away is that it is important to carefully reflect on the outcomes data supporting our quality metrics and that we also find merit in ACP for hospitalized patients with older age or serious illness.
Written by Molly Kantor