Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)

Abstract

COVID-19 has highlighted the reality of an impending serious illness for many, particularly for older persons. Those faced with severe COVID-19 infection or other serious illness will be faced with decisions regarding admission to intensive care and use of mechanical ventilation. Past research has documented substantial medical errors regarding the use or non-use of life-sustaining treatments in older persons. While some experts advocate that advance care planning may be a solution to the problem, I argue that the prevailing understanding and current practice of advance care planning perpetuates the problem and results in patients not receiving optimal patient-centered care. Much of the problem centers on the framing of advance care planning around end of life care, the lack of use of decision support tools, and inadequate language that does not support shared decision-making. I posit that a new approach and new terminology is needed. Advance Serious Illness Preparations and Planning (ASIPP) consists of discrete steps using evidence-based tools to prepare people for future clinical decision-making in the context of shared decision-making and informed consent. Existing tools to support this approach have been developed and validated. Further dissemination of these tools is warranted.

Factors associated with concordance between POLST orders and current treatment preferences

“…A sizeable minority of POLST forms were comfort‐focused and these were significantly more likely to be concordant with current preferences than POLST forms documenting preferences for higher levels of interventions. This finding is consistent with prior research suggesting greater stability when baseline preferences are to forgo or limit treatment 35‐37 and may reflect greater certainty about the resident's medical condition and the context of decision‐making 38 . Interestingly, the initial intent of POLST was to ensure nursing facility resident preferences for comfort were honored, 1 as a decision to focus on comfort is a departure from default treatments.…”

Implementation of advance care planning amid the COVID‐19 crisis: A narrative review and synthesis

“…The design of the primary studies was retrospective observational ( n = 4), 17–20 comparative cross‐sectional ( n = 1), 21 design process ( n = 2), 22,23 quality improvement intervention ( n = 1), 24 case report/study ( n = 2) 25,26 and virtual workshop ( n = 1) 27 . The rest of the articles were perspective papers ( n = 5), 3,28–31 letters to the editor ( n = 2), 32,33 newspaper analysis ( n = 1) 34 and guideline review ( n = 1) 35 . The primary studies were conducted in the USA, UK, the Netherlands, Japan and Taiwan.…”

POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care

“…It also helps ensure that decisions are made within the context of serious illness when the burdens and benefits of available treatments are more likely to be known. 3 POLST use is meant to be voluntary and patients should never be required to have a POLST.…”

“…Moreover, many of these patients expect to return to baseline, making it challenging to make informed decisions about the benefits and burdens of treatment options or even what treatment decisions may be relevant to their yet unknown health condition. 3 For such relatively healthy patients, and even for many frail, chronically and seriously ill, POLST-appropriate patients who do not have specific preferences about initial treatment in the event of a sudden cardiac or respiratory arrest, there is no need to invoke POLST orders at all. In the absence of explicit orders for Do Not Resuscitate/ Do Not Attempt Resuscitation (DNR/DNAR), the default treatment is always for full-code status, including CPR and intubation.…”