Advance Care Planning in the Elderly

Key points

What is advance care planning?

ACP is the process of planning for future medical care with the goal of helping patients receive medical care that is aligned with their preferences, especially in the setting of serious illness or as the end of life approaches. Table 1 provides common terms and definitions used in ACP. For example, one component of ACP is advance directives, which include medical power of attorney appointments or living wills; these written forms facilitate end-of-life decision making based on a patient’s

The need for advance care planning in the elderly

Benefits of ACP include the following:

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  Ability to identify, respect, and implement an individual’s wishes for medical care, especially in the absence of decision-making capacity, during serious illness, or near the end of life²

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  Ability to manage personal affairs while able, peace of mind, less burden on loved ones, and peace within the family⁶

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  Reduction in stress, anxiety, and depression in surviving family members⁴

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  Improved patient satisfaction and quality of life7, 8

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  Decreased use of intensive

Key concepts in advance care planning

Key steps in ACP are (1) assessing patient readiness and identifying barriers, (2) identifying surrogate decision makers, (3) asking about individuals’ values related to quality of life and serious illness, (4) documenting ACP preferences, and (5) translating individuals’ preferences into medical care plans. Table 2 summarizes brief approaches to each key concept.

ACP is a stepwise process that does not need to occur in a single clinic visit; it is a process that can unfold over time. For

Special considerations for advance care planning in the elderly

As clinicians and the outpatient care team undertake ACP, there are special considerations to account for in the older adult, such as:

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  Presence of cognitive impairment, suggesting the need to assess decision-making capacity³⁸ related to ACP and to involve surrogates if available

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  Living apart from a potential surrogates (ie, long-distance family member)

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  Lack of available surrogates owing to absent or fractured relationships or the death of loved ones

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  Prior ACP, especially advance directives that are

Team-based approaches to advance care planning

As patients engage in ACP, clinicians and the outpatient care team can work together to support ongoing values: clarification discussions; education and counseling about risks, benefits, and burdens of medical treatment options; and communication with patients, surrogates, and the health care system as patients’ health status, needs, and preferences change over time. The multidisciplinary team can use the key concepts as guides to identify how patients may have engaged in ACP or brief

New patient-centered advance care planning tools

Recent advances in ACP include the development of accessible tools to assist patients with knowledge and decision making related to ACP. Because ACP can be a personnel-intensive and time-intensive process, helping patients and families begin this process on their own is useful. In a randomized controlled trial, a patient-completed preference form increased ACP communication from 11% to 30%.⁴¹ Although not all tools have been formally tested in research settings, various tools offer practical

Summary

Clinicians who care for older adults can engage older adults in ACP through multiple brief discussions over time. ACP emphasizes choosing a surrogate decision maker, identifying personal values, communicating values and preferences with surrogates and clinicians, documenting preferences for future medical care, and appointing a surrogate decision maker in advance directives in addition to, when appropriate, translating preferences into specific medical treatment plans or medical orders. While