Advance care planning is an art, not an algorithm

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The article by Drs. Messinger-Rapport et al in this issue of the Cleveland Clinic Journal of Medicine makes several assertions about advance care planning with which I disagree. As a practicing oncologist and hospice medical director in a community setting for almost 20 years, I believe the authors’ attempt to reduce a complex physician-patient interaction to a practice algorithm oversimplifies the issues.

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I agree with the authors that advance care planning is an oft-mentioned but underperformed function of being a physician in current American society. Our nation has become a people who deny physical vulnerability, frailty, and death. This area is not well taught in our medical schools and residency training programs.

However, the algorithms in the paper do not effectively address the timing and process of advance care planning. It is clearly not effective to have an end-of-life discussion at the bedside of a critically ill patient about to be intubated. It also seems futile to have a superficial discussion with patients about advance care planning at a time when they are healthy and in the setting of a routine and brief office visit. In this healthy population, the episodic discussions recommended by the authors could become background noise and could seem irrelevant to a patient. Physicians are already overburdened with responsibilities. Re-educating society that lives are not infinite is a social issue that needs to begin early in our lives.

In any setting, a social history, properly taken, should identify family structure, responsible next of kin, and family issues of discord that could affect treatment decisions and patient care. This is all that is needed as a minimal discussion about advance care planning.

Once patients develop significant illness, speaking to them about advance care planning becomes more relevant to their lives. As patients struggle with their illnesses and physical decline, the opportunity for further discussion grows and the impact of these interventions becomes greater. The energy and time it takes to have such discussions are better spent in these settings.

Discussing long-term planning with a patient is where intuition, experience, and training play a vital role. The balance between the pragmatic need for advance care planning and the need for allowing the patient to have hope of wellness is difficult to achieve and different for every patient, every family, and every care situation. It is for this reason that I find the flowcharts outlined in the paper difficult to follow and not very useful for the care of patients. Given the diversity of patients for whom we care, it seems impossible to me to condense the subject down to a care-flow matrix. This is an area in which the art of patient care and the art of being a physician come fully into play and cannot be replaced by an algorithm. Individual and small-group training with mentors, at all levels of medical education, would allow a physician to grow in comfort and skill in dealing with advance care planning.

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