Advance care planning: Easing the difficult conversation

Today, people in America are living eight years longer on average than what could be expected for their grandparents and even their parents. Thanks to a combination of significant medical advances and an increased national focus on health and fitness, seniors have more time for travel, community service, new career ventures, loved ones and other activities. Plus, they can enjoy a better quality of life.

But even with this encouraging news, it’s still important that we give thought to the end of our lives. Remember the famous Ben Franklin quote about death and taxes? Well, it’s true. They are both certain in life. Unfortunately, we’re still better at planning for taxes than planning our final days.  That needs to change.

Starting the conversation

Death is a difficult topic to broach. We don’t want to accept our, or our loved ones’ mortality. However, we must get comfortable with the conversation, and advance care planning should be at the heart of this discussion.

Most of us in the United States are not dying the way we want, and the majority of the time, lack of planning is the root cause. Despite the fact that 80 percent of Americans would rather die at home, 60 percent die in acute care hospitals and 20 percent of die in nursing homes, according to the Stanford School of Medicine. Sadly, only 20 percent die at home in the way they had preferred.

These statistics not only represent a harsh reality for patients and their families, but the trend is also an expensive one, costing the U.S. healthcare system billions of dollars. And unfortunately, this spending does not necessarily result in better health outcomes for patients or satisfaction with the care received, according to the Annals of Internal Medicine.

Therefore, it’s critical for older Americans, along with their doctors and their families, to begin conversations about advance care planning—and to consider hospice as part of the equation. The reasoning is simple: Hospice allows appropriate patients to live longer, stay at home and have an increased level of comfort, according to the National Hospice and Palliative Care Organization’s 2010 study. It allows people to live their final days as they desire.

Unfortunately, patients nearing the end of their lives are often in the wrong care setting. In addition, the Stanford study cited earlier revealed that only a minority of dying patients get to take advantage of hospice care. And, those patients are usually referred to hospice in just the final three or four weeks of life, which is too late (the hospice benefit is 180 days). That’s why it’s crucial that advance care planning and end-of-life care conversation happen sooner rather than later. It empowers the patient to make an informed decision for him or herself.

There is good news, however. Increasingly within the health care industry, end-of-life conversations are being encouraged, and Medicare’s advance care planning policy is covering up to $86 for an office-based counseling session, as of this year.

Who initiates the discussion?

Most people—89 percent—rely on clinicians to begin the conversation about end-of-life care. The discussion may include family and friends, and it should provide information about the various options for care, allowing patients to make informed decisions.

The most effective conversations happen when clinicians know which patients are ready to have them. That’s where predictive analytics comes in. A predictive analytics tool can analyze patient data and provide caregivers with mathematical insight into which patients could benefit from a different type of care and when. These analytical insights, paired with a clinician’s education, experience and instinct, can enhance care decisions and result in more timely and appropriate care conversations.

For example, end-of-life analytics solutions use patient data to predict when patients could be better served with hospice care. With this information at hand, clinicians can identify patients needing these time-sensitive discussions earlier than if they were not using an analytics solution. Patients and their families then have more information­—and more time—to make the best decisions for their end-of-life care.

When to start the conversation

Post-acute clinicians should begin advance care planning conversations if they observe any of the following events: 1) a patient is admitted to your facility, 2) a patient shows consistent decline instead of improvement during a home health episode, 3) a patient says he or she is tired of being hospitalized for a chronic illness, or 4) a patient appears in analytics-based hospice benefit risk stratification list.

Keeping communication open

These big end-of-life decisions are not usually made after one conversation. Caregivers should use the initial discussion about advanced care as an opening to future ones. It can be a lot for people to digest, and repetition will likely be necessary. In addition, patients will need to have time to absorb the information and discuss it with their families and those who are closest to them. By addressing all of a patient’s options, including hospice and a thorough explanation of what hospice is, you’ll be facilitating the best care for the patient. Only with the best information can a patient make the best decision for him or herself. Your duty as a caregiver is to ensure that the right patient is equipped with the right information at the right time to make that decision.

All clinicians—no matter their discipline or specialty—should understand basic palliative care and be skilled in communicating end-of-life issues with patients, according to “Dying in America,” a report by the Institute of Medicine. But that doesn’t mean that it’s easy. Having an established method to identify patients who might benefit from an end-of-life care conversation can be extremely helpful, and Medalogix encourages all caregivers to leverage analytics to help identify patients who might be in need of different or more care.

We all have a right to live the end of our lives in comfort and dignity. To ensure that patients consider their options and make decisions around advance care while they are still able, caregivers and specialists must get comfortable having difficult conversations. And, it’s up to all of us to keep the lines of communication open.

Dan Hogan is founder and CEO of Nashville, Tennessee-based Medalogix, a healthcare technology company that provides analytics and workflows to home health providers.

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