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Advance Care Planning

Overcoming Physician and Patient Barriers to Advance Care Planning

April 9th, 2024 | 7 min. read



Content Team

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Advance Care Planning (ACP) adoption is picking up steam, but documented barriers keep physicians and patients from engaging more widely. A team-based care management approach can overcome those barriers, yielding numerous benefits for the provider, patients, and their families.

ACP benefits can outweigh the effort to overcome barriers

Not having ACP documentation and a healthcare proxy can put physicians and patients’ families in challenging situations. They must make decisions without the patient’s expressed wishes for medical care.

However, proactive Advance Care Planning provides valuable benefits. It aligns patients' care with their values and preferences, improves caregiver outcomes, and decreases the likelihood of undesired end-of-life care and costs.

Six strategies can help mitigate physician and patient barriers and actively support both groups to embrace the ACP process.

Physicians face three main barriers

Advance Care Planning should proactively document essential medical treatments that would or would not be desired if the patient cannot speak for themselves. 

However, three common barriers can prevent physicians from providing ACP services. 

1. Lack of time

Physicians are already pressed for time to provide adequate care and guidance for current medical conditions and concerns. 

Strategy to overcome: Use a team-based care management approach. By leveraging a care team through a program such as Chronic Care Management, providers can increase clinical capacity. ACP responsibilities can be shared across appropriate roles and professional licenses.

Research has shown that nurse-facilitated ACP in a primary care setting can be equally effective as when a physician leads. Additionally, team-based models, including a physician, registered nurse, certified nursing assistant, or social worker, were considered cost-effective and supportive of quality outcomes.

The key is to focus physician time on the areas that best fit their training and value on the care team. Other clinicians – such as physician assistants, nurse practitioners, and certified nurse assistants – can provide the bulk of the planning aspects within the ACP process. 

If the physician is involved, they can focus on areas like discussing the patient’s health status and disease trajectory or the effectiveness and repercussions of choosing various medical interventions. 

2. Ensuring reimbursement

It doesn’t make good business sense for a physician to participate in services that aren’t paid. 

Strategy to overcome: Leverage Medicare coverage. ACP services are reimbursable under Medicare coverage. Plus, if ACP is provided as part of the Annual Wellness Visit (AWV), there is no cost-sharing for patients.

3. Inadequate training 

Physicians receive little to no training in medical school or residency about Advance Care Planning. Many are uncomfortable discussing end-of-life issues and would rather focus on diagnosing and treating current conditions.

Strategy to overcome: Integrate an evidence-based ACP workflow. ThoroughCare offers an integrated ACP workflow that supports patient-facing educational resources. By guiding clinicians through the entire Advance Care Planning process, ThoroughCare allows the physician and care team to focus on the patient without worrying that they need to have all the answers. 

Why physicians should adopt Advance Care Planning

Using these three strategies to overcome barriers enables physicians and their provider organizations to harness multiple benefits from offering ACP services, including:

  • Easing the physician’s decision-making burden by knowing the patient’s desires
  • Decreases risk and increases patient and family satisfaction and cooperation when it comes time to make tough decisions
  • Provides a crucial medical support service with corresponding reimbursement

Beyond these personal and professional benefits to physicians, research has shown that ACP significantly improves multiple outcomes, particularly for patients with serious illnesses, including:

  • Reduced hospitalization at the end of life
  • Fewer intensive treatments at the end of life
  • Increased utilization of hospice services 
  • Increased likelihood that a patient will die in their preferred place

Patients face three main barriers

1. Discomfort with mortality

Many topics surrounding death are still taboo. Plus, healthcare professionals tend to focus solely on diagnosing and treating current conditions rather than thinking about future healthcare decisions.

Strategy to overcome: Normalize Advance Care Planning. Research has debunked the misconception that patients don’t want to talk about possible future medical decisions.   

One study found that patients valued the opportunity to speak about issues important to them, and saw the approaching clinician as compassionate and caring. Patients believed that Advance Care Planning could significantly benefit them and their families.

With a care management program, such as Chronic Care Management, care teams can integrate ACP as part of the regular cadence of medical practice. Plus, by raising awareness throughout the year and conducting ACP during an Annual Wellness Visit, patients know what to expect and are more open.

2. Misunderstanding the purpose and benefits of ACP

Research shows that patients have inaccurate beliefs about Advance Care Planning and how medical decisions are made when they can’t speak for themselves. 

In one study, patients were asked seven key questions about ACP. Only 11.9% of participants answered all seven correctly, and nearly 25% answered less than three correctly. 

Strategy to overcome: Integrate and facilitate accessible ACP education. ThoroughCare provides a guided approach through each step in the ACP process, including:

  • Choosing a medical decision-maker (aka proxy)
  • Exploring patient values
  • Identifying healthcare priorities
  • Reviewing treatment preferences
  • Discussing and choosing medical interventions
  • Creating legal ACP documents for all US states

In addition to a standard approach to ACP, ThoroughCare integrates multimedia materials and videos that clinicians can use to provide education for all literacy levels. Education helps to dispel long-held myths and empowers patients to make decisions that represent their values and preferences.

3. Insecurity about involving family

Advance Care Planning creates clear directives for patients who can’t communicate their wishes and treatment desires. Without ACP, many burdensome decisions fall on the family. 

While creating ACP documents empowers patients to capture their preferences, Advance Care Planning shouldn’t be done in isolation. Ideally, a patient’s closest relatives or friends should know that ACP documents exist and what decisions they contain. 

Most importantly, the patient should select one medical decision-maker or proxy and a backup from those closest to them.

Strategy to overcome: Leverage a holistic ACP method. Care teams that create awareness and make Advance Care Planning a standard part of medical care can leverage ThoroughCare’s integrated workflow to maximize patient and family engagement.  

Invite the patient to include a family member during the Annual Wellness Visit, during which advance planning topics will be discussed. Use integrated multimedia education to explain to patients and families the importance and value of ACP. 

The platform can then be used to make ACP documents accessible in digital form 24/7. The patient can also create a video living will and provide contact information for those with whom they want to share their ACP preferences.

Why patients should adopt Advance Care Planning

Using these three strategies to overcome barriers enables patients and their families to experience the many benefits of ACP services, including:

  • Greater control and power over one’s desired care
  • Increased family confidence and fewer burdens when called on to make medical decisions
  • Clarity around the efficacy and usefulness of available medical interventions in light of the patient’s preferences

When supported by clinicians and backed by evidence-based education, Advance Care Planning has been shown to “lower stress, anxiety, and depression in surviving relatives of deceased persons.” This is most likely due to the proactive conversations that helped loved ones know the patient’s preferences and because they were better prepared to make decisions.

ThoroughCare helps patients and providers understand Advance Care Planning

As a care management platform, ThoroughCare provides a standardized and integrated workflow that clinicians can use to support patients and their families in planning for possible future medical decisions.

Through evidence-based multimedia education and guided steps, care teams can feel confident facilitating conversations with patients to ensure their preferences are known and honored.

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