Care Transformation Center Blog

Addressing advance directives in population health management

Tomi Ogundimu

Today is April 16, which means it’s National Health Care Decisions Day.

This day is part of a nationwide focus on end-of-life planning and advance directives education (advance directives are legal statements outlining a patient’s wishes for medical treatment during end-of-life situations). Discussing these emotionally fraught topics is an important step for care transition planning, and we've seen many population managers already making end-of-life planning an integrated part of their approach for managing population health.

Three common errors around advance directives

I recently had the opportunity to speak with a national expert on advance directives, Dr. Ferdinando Mirarchi, DO, the medical director of UPMC Hamot’s emergency department. In recent years, he led a three-part nationwide study to increase patient safety through improved interpretation and understanding of advance directives, known as The Realistic Interpretation of Advanced Directives—or TRIAD study.

This research surfaced three common problems that consistently led to unnecessary complications around advance directives.

  • Most directives are templates, and are not customized for individual patients
  • Patients often do not understand their directive and provide misinformed—not informed—consent
  • Most medical personnel are never educated on the nuanced differences in advance directives, resulting in a misinterpretation of patients’ wishes

As Dr. Mirarchi will tell you, it's important to understand that an advanced directive does not always equal an order for no treatment or resuscitation.

Addressing this issue demands that clinicians learn more about advanced directives. Organizations should also embed safeguards into care protocols to ensure that physicians can understand and comply with advance directives.

There are two strategies organizations can adopt to be more proactive.

1. Translate legal jargon into language that medical personnel will readily understand

A series of QuantiaMD surveys found that nearly 60% of medical personnel could not correctly interpret a patient’s advance directive. Living wills, which are one type of directive, are often written by lawyers. Legal language complicates a clinicians’ ability to interpret the directive—particularly in high-pressure moments that require prompt decision-making.

To protect against misinterpretation, organizations can proactively embed a designated code status prominently in a patient’s living will. This can help clarify a patient’s wishes in language clinicians are more accustomed to.

2. Integrate a “checklist” approach into end-of-life care

Checklists are often integrated into health care to prevent medical errors by reducing clinical ambiguity, and they can play a role with advance directives.

Dr. Mirarchi developed checklist for patients with advance directives, known as the “resuscitation pause.” Using a short A-B-C-D-E algorithm, physicians use the checklist to pause in all situations with advance directives to ensure that patient wishes are fully understood.

1. Ask patients or caregivers about the intention of the advance directive.

2. Be clear about the patient’s condition—differentiating terminal, non-treatable conditions from critical, treatable ones.

3. Communicate clearly with patients and care team members if you feel a patient’s condition is reversible and/or treatable.

4. Discuss next steps with patients or caregivers using an action plan to determine how to respond to a patient’s wishes under critical conditions.

5. Explain to all involved in a patient’s care—from family members to the care team—that it is okay to withhold or withdraw certain care if it correlates with the patient’s perceived wishes. This can set the stage for discussions around hospice and palliative care.

These safeguards are two examples of how a better understanding of advance directives can be integrated in your overall population health management approach. Being proactive not only ensures that you will better match patient wishes, but it’s a great lever to help right-size care by minimizing overtreatment.

Learn More

Access this lecture on advance directives to learn more from Dr. Mirarchi on this tenet of end-of-life management.

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