Advance care planning should never be considered a “one and done” activity but an ongoing conversation revisited frequently, especially in the last several years of life. Making our wishes and surrogates known is an important conversation, even as relatively healthy adults. As we age, it becomes increasingly important that those providing our care and supporting us know how we would like to live the end of our lives. An advance care plan is not just about how we want to die. It is really more about how we want to live.
Although encouragement to talk about advance care planning can come from family or even estate planners, health care providers are often engaged to initiate this conversation. This discussion frequently focuses on the types of treatments or lifesaving interventions a patient or their family prefer at the end of life, such as: hospitalization or not, intubation or not, resuscitation or not. Many states have adopted Provider Orders for Life-Sustaining Treatment (sometimes called POLST or MOLST). These forms uniformly document specific orders that can be shared with providers. Skilled nursing facilities (SNFs) and assisted living facilities (ALFs) need this information immediately upon admission to allow them to take appropriate action if a change of condition occurs. But, this document should not be “the” advance care planning conversation.
With an ongoing relationship (and frequent visits within SNFs and ALFs), providers have the opportunity to delve into the patient’s preferences and wishes for living. Understanding their priorities and desires beyond health care treatment can begin to paint a picture of the life they want to lead in their last years.
Advance directives should be readdressed with any changes in health status or life transitions. Factors driving end-of-life decisions are often more complicated than just changes in a medical condition. The death of a close family member, the passing of life milestones, and changes in functional ability or living conditions may influence a patient’s end-of-life planning more than significant medical changes.