Advance Care Planning: A Paradigm Shift

According to Merriam-Webster dictionary, a paradigm shift occurs when “an important change happens when the usual way of thinking about or doing something is replaced by a new and different way.” In the last year, we have seen the introduction and passage of legislation surrounding palliative care, advance care planning mechanisms for billing from the Centers for Medicare & Medicaid Services, as well as continued debate in the 2017 legislative session regarding health care decision maker policy. Every year, April 16 marks National Healthcare Decisions Day. In 2017, this recognition is being extended to a full week starting April 16 and ending on April 22. This extension, as well as the other initiatives mentioned above, is a promising sign of a coming paradigm shift in how we respect all phases of life.

In 2016, the Missouri legislature passed Senate Bill 635 and several other bills that included language on palliative care. Senate Bill 635 established within the Department of Health and Senior Services the “Missouri Palliative Care and Quality of Life Interdisciplinary Council.” The bill outlines the members of the council, including physicians, nurses, social workers, spiritual professional, patients and families, and members of the House and Senate. The primary charge of the council is to improve quality and delivery of patient-centered and family-focused care in Missouri. Signing up for the council is relatively easy on the Missouri Boards and Commissions’ website, or you can contact Ted Wedel, MHA’s Vice President of Policy Development.

Medicare also plays an important role in supporting the shift in advanced care planning. In November 2016, Kaiser Family and The Journal of the American Medical Association released an article on Medicare’s role in end-of-life care. The “Medicare and End-of-Life Care” figure was depicted in the article. The importance of Medicare’s role is supported by the fact that in 2014, four out of five people who died in the U.S. were Medicare beneficiaries. In addition, most people older than 65 have not discussed care wishes with their physician. This could be the result of most physicians reporting that they were not trained to discuss end-of-life care. In addition, July 3 marks the implementation date of the Advance Care Planning Implementation for Outpatient Prospective Payment System claims. Physicians and providers will be able to submit claims for the explanation and discussion of advanced directives including documentation of conversations. CMS also is including voluntary ACP as an optional element of the annual wellness visit where a face-to-face discussion of advanced directives occurs between the physician and patient, with or without the completion of relevant legal forms.

Missouri has long had the debate in the Capitol regarding health care decision-making. Missouri has been host to critical events in the past, challenging the ethical and legal realms of end-of-life care. The Missouri legislature has been working on a systematic approach as to who can make health care decisions for someone who is not capable of making them on their own for several years. House Bill 144, introduced by Rep. McGaugh, was referred to the legislative committee and voted a “do pass” by the committee. MHA will continue to monitor the progress or lack thereof of this bill. If Missouri citizens had advanced directives in place, the need for legislation like House Bill 144 would significantly diminish.

We need to be involved. Health care providers need to be involved in policy development and oversight; in educating ourselves on how to have advanced care discussions; in advocating for improved instruction in institutions of higher learning for physicians, nurses, social workers and chaplains; in structuring events where we actively educate our communities on the importance of its population having care discussions and plans in place. There is no one better suited to initiate these important conversations with patients and families than our providers and hospitals. There are two conditions which unite us all — birth and death. We spend enormous amounts of time and money to provide perinatal education, birthing classes, birthing plans and environments conducive to a comforting birthing experience. The most basic instruction in advanced care planning helps patients clarify their wishes, make choices and tailor their care in ways that preserve whatever gives them meaning and comfort. The choices are as varied as the people who make them. Everyone should complete an advanced directive and discuss their wishes with a loved one, friend or others.

The nature of prognostication means we will sometimes be wrong. And the nature of disease means we will sometimes have no cure to offer. But the nature of hope is a paradigm shift embedded in clarifying a patient’s wishes, providing choices and attempting to help them and their families define their hope and shape their decisions for the best possible outcome. We, as health care providers, have the ability to help our patients create a paradigm shift with each interaction we have with them.