10.1.1 Step 1: Using Advance Care Planning Forms to Inform Goals of Care Discussions

The first task in documenting goals of care is to review patient’s medical record for past goals of care discussions and documentation, and/or to ask patients if they have previously completed advance directive forms. Advance health-care directives are legal documents that list a patient’s preferences for life-sustaining treatments and/or the person whom they would like to make decisions should they not be able to make them on their own (a surrogate or health-care proxy). Some hospital systems may include copies of a patient’s advance directive in the medical record. You can also ask the patient or their family to supply a copy.

Documentation of whether the patient has an advance directive, its content, and the stability of preferences should be included in an admission note. If an advance directive can be obtained, note the date the document was signed, as it may have been executed in the distant past. Asking patients to describe previous discussions concerning advance directive completion could provide a good starting point for your current discussion. Confirm that the listed health-care proxy is correct, as is the alternate proxy, and that their contact information is accurate. Review any treatment preferences outlined in the document to ensure the patient still feels similarly. Potential questions include: “Your prior advance directive said X. Do you still feel the same way? Have you changed your mind about any of your preferences?”

If no prior documentation is available, education can be provided about the advance care planning process; this can often provide a smooth transition into discussion of goals of care or, at the very least, identification of a surrogate decision-maker should the patient lose capacity to make medical decisions.

10.1.2 Step 2: Completing Advance Care Planning Forms Based on Goals of Care Discussions

After the discussion, the next step is to document the outcomes of this discussion on a legal, advance care planning form (summarized in Table 10.1). Inpatient social workers can often help with this task once the wishes are known.

An advance health-care directive, which includes a health-care proxy document, an instructional directive, or both, can be critically helpful. In a recent study by Silveira [5] of adults who were over age 60 and died between 2000 and 2006, 42% required decision-making about treatment in the final days of life, and 70% of those patients lacked decision-making capacity. The health-care proxy helps medical providers know whom the patient has chosen to make decisions on their behalf. The instructional directive may then give some guidance to clinicians and surrogate about the types of treatments a patient would want in given situations. Instructional directives often contain standardized language about various treatments in different clinical scenarios.

State-approved physician orders for life-sustaining treatment forms (a.k.a. POLST) translate a seriously ill patient’s preferences for life-sustaining interventions into actionable medical orders. The POLST is a standardized form that provides instructions regarding CPR and medical orders that indicate the patient’s desired level of medical intervention (i.e., intubation, artificial nutrition, antibiotics, rehospitalization). Once signed by the patient (or their legally designated surrogate decision-maker if the patient has lost decision-making capacity) and their medical provider (typically MD though varies by state), the form serves as a standing medical order. The POLST form can then travel with the patients as they move from one setting to another, thereby ensuring that their physician orders travel with them. The states participating in the POLST program are listed at http://www.polst.org/programs-in-your-state.

A POLST form is different from an advance directive. The POLST forms provide specific orders for current treatment; in contrast, advance directives specify patient preferences for future treatment. In addition, POLST forms are only intended for patients with serious, life-limiting illness or patients with advanced chronic illness (such as frail nursing home patients), whereas all patients may complete an Advance Directive. We recommend that, if available, a POLST form is used as a complement to the advance directive in patients with serious or life-limiting illness.

An older iteration of the POLST form is the out-of-hospital do not resuscitate form, which is also a physician’s order. This form must be signed by a medical provider (check your state’s laws for details) and refers only to a patient’s desire to forgo CPR. This document is intended for use outside of the hospital.

Laws related to advance directives, POLST-type forms, and oral advance directives vary by state. Please refer to the “American Bar Association, Commission on Law and Aging” (website: www.abanet.org/aging) to review state-specific laws related to advance directives. A list of suggested advance directive resources is provided at the end of the chapter.