"Physicians have a responsibility to help patients define their goals for end-of-life care and to respect patients' preferences," states the AMA Code of Medical Ethics. Yet, as noted in this AMA Steps Forward® module, only an estimated one-third of U.S. adults has completed an advance directive. While patients are responsible for preparing their own end-of-life documents, physicians play a key role in encouraging patients to make their wishes known. Time constraints and feelings of overwhelm are understandable challenges, but here's why it's worth prioritizing end-of-life care discussions with your patients:
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Helping patients identify what matters most to them at life's end—what interventions to accept, when to refuse life-sustaining efforts, whom they'd like to name as a health care proxy—is not just for those with terminal illnesses or chronic medical conditions. Anyone 18 and over can and should create an advance directive, even young and healthy people. Doing so helps avoid receiving unwanted, costly or high-intensity care that may not improve quality of life. Many patients may not realize they have choices about how they're treated if recovery from illness or injury is improbable.
End-of-life care is challenging and often complicated. Creating a living will, assigning power of attorney, or stating health care instructions can be clarifying for both the care team and a patient's family in the event the patient becomes ill and lacks decision-making capacity. As the CDC explains, "A plan relieves family members from wondering if they ‘did the right thing' on [a patient's] behalf." The possibility of reducing conflict and providing peace of mind may motivate patients to complete an advance directive.
The rise of palliative care as a clinical specialty has placed greater emphasis on advance directives. Knowing a patient's goals puts physicians and health care professionals in a better position to provide medically sound care that aligns with the patient's values and wishes. Recognizing this, the AMA STEPS Forward series, in collaboration with Stanford Medicine, offers four steps to plan for end-of-life decisions with your patients.
Clinicians may lack time or training to broach the topic of end-of-life decision-making. An end-of-life letter makes it easier. It's personalized, accessible and free of medical and legal jargon. While such templates are not legally binding, patients and their families may use the completed letter as a guide for a health care power of attorney. Advise patients to update their letter as appropriate (e.g., if they have a major change in health status). This tool from the Stanford Letter Project turns letters into advance directives for free.
While discussing end-of-life care decisions may be uncomfortable, it's important to routinely engage patients in advance care planning and encourage patients to put their preferences in writing.
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