Advance Care Planning Beyond the Documentation

April 25, 2022

One of the main goals of Advance Care Planning (ACP) is the completion of a legally recognized Advance Directive (AD). This and other legal documents help guide medical decision-making and ensure treatment is consistent with a patient's expressed wishes should they no longer be able to speak for themselves. 

However, simply executing legal documents as the most important outcome from ACP conversations can leave an incomplete picture of a patient's goals and preferences for future care. 

That is where Comprehensive Advance Care Planning (CACP) conversations conducted by licensed and skilled healthcare experts stand apart. Iris facilitations and the CACP process go beyond documentation and dig deeper into a patient's values,  goals of care and quality of life. 

CACP Beyond The Document 

There is a bigger conversation that needs to happen beyond what is in the various state-regulated AD forms, which typically address only what happens when a patient is actively at or near end-of-life.  

Even more important than the state-sanctioned legal form is the engagement with topics that maybe haven’t been addressed before. This conversation includes asking uniquely personal questions such as: What is important to that patient? What matters most in their life? What would represent living well in the face of illness? What happens as independence starts to wane? 

There is often still a lot of living to do between the time a serious illness is diagnosed and the end-of-life. And just like with any other planning process, results are better if we plan ahead and carefully think through different scenarios and options. 

Personalized CACP Conversations

These delicate CAPC conversations require a sensitive and empathetic human touch because it is not a topic that most people look forward to discussing. Through tailored conversations with patients and their loved ones, Iris facilitators personalize the outcome to the values and needs of each patient.  

Iris facilitators are skilled at asking the kinds of questions that can put patients at ease and help them open up and consider what might happen in the future. If the patient has been sick for a while, this is probably not the first time they have thought through these questions or scenarios. Having an expert-led discussion can help with processing, understanding and verbalizing their preferences. 

Ideally, the process leads to both completed documentation and a greater awareness and support within the family and care team about values, goals of care, and treatment preferences.

Involving Loved Ones and Caregivers

CACP is not just for patients; their families and caregivers are key players in this process as well and should be included in CACP conversations from the outset. Oftentimes, these individuals bring crucial insights to the discussion, acting as a sounding board for the patient as they work through their care goals. 

Additionally, including family members and caregivers in the CACP process ensures they know exactly what patients want if they are ever in a position to make decisions on the patient’s behalf. 

CACP Documentation Tailored to the Patient 

Typical state documents only cover a fraction of the different situations that could arise. Decisions in healthcare, especially those around serious or advanced illnesses, are never black and white. The comprehensive and personalized CACP process is a vehicle for capturing some of those “shades of gray” areas and documenting them. 

Iris’ proprietary Goals and Planning Summary (GPS) is a personalized treatment summary and addendum that goes beyond the legal directive to incorporate the patient’s values and wishes in their own words. This document is shared with loved ones, clinicians, points of care and anyone who the patient thinks should be aware of their wishes. 

Uncovering Barriers to Realizing CACP Plans

Iris CACP facilitations provide an additional way to uncover potential barriers to realizing a patient's care preferences. In some situations, a patient may prefer to stay at home and avoid the hospital or assisted living facilities, but is worried about being a burden, financial or otherwise, to their loved ones. 

If independence is most important to a patient, and certain treatments might affect their independence, they need to know that. If they can’t walk but live on the second floor, with no way to get out, what is realistic then? Iris facilitators are trained to surface these kinds of barriers to a patient realizing their care plan. What could blow up the best-laid plans? How can the patient overcome these barriers?

Simply put, creating and signing advance directives is not enough to maximize the benefits of CACP. To truly improve the patient experience, practices can partner with Iris to create high-quality care plans across their high-risk patient population. The Iris team of trained CACP experts ensure patients are provided with a tailored, person-centered experience. As a result, the Iris CACP service has been proven to boost patient and clinician satisfaction and reduce unwanted care utilization.