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Advance Care Planning- Beyond the Document

Wednesday, May 26, 2021

One of the goals of Advance Care Planning (Advance Care Planning) , including the facilitated, remote, virtual goals-of-care conversations that are offered by Iris Healthcare, is the completion of a legally recognized document called an Advance Directive (AD). Three common forms for advance directives are the Living Will, Durable Power of Attorney for Health Care, also referred to as Medical Power of Attorney (MPOA), and Physician Orders for Life-Sustaining Treatment (POLST).

These documents are important tools in helping to guide serious medical decision-making to be consistent with an individual’s articulated values, goals and preferences at a future time should they no longer be able to speak for themselves. Simply executing such legal documents as the only, or even the most important outcome, from advance care planning conversations can leave an incomplete picture. That is where expert-led Iris Advance Care Planning phone and video facilitations that are conducted with clients and their families stand apart from the crowd. Our facilitations and Advance Care Planning processes are designed to go beyond just the documentation.

More Than Just a  Document 

There is a bigger conversation that needs to happen beyond what is in the various state-regulated AD forms, which address the life sustaining treatments an individual may or may not want in certain future medical circumstances. This includes asking important and uniquely personal questions such as: What is important to that individual, what matters most in their life, what would represent living well in the face of illness, what happens as independence starts to wane? 

“Even more important than the state-sanctioned legal form, is the engagement with questions that maybe haven’t been addressed or asked before,” says Iris Healthcare CMO Stephen Bekanich, MD. The state forms address what happens when someone is dying. .  The Iris process of working with individuals is interactive and not just checking off boxes on a legal form. “There is a lot of living to do between the time a serious illness is diagnosed to the process of dying. And just like with any other plan, results are better if you plan carefully and think through different scenarios and options.” Dr. Bekanich said.

“Through our conversations with clients, we personalize the outcome to the values and style of the individual member,” says Elaine Cannizzaro, Iris VP of Member Services. “We have a structured set of questions we ask, but no two conversations are ever the same.” Ideally, the process leads to both a completed advance directive and a greater awareness and support system within the family about values, goals of care, treatment preferences, and what is within the realm of the possible. “Sometimes the document is absolutely necessary and, if you don’t have one, it will make the situation harder for loved ones trying to make decisions in the time of a medical crisis when stakes and emotions run very high. At the same time, typical advance directives only cover a fraction of the different situations that could come up. That’s why you want to be on the same page with your loved ones,” she says.

Decisions in healthcare, especially those around serious or advanced illnesses, are never black and white, she adds. “Our comprehensive and personalized Advance Care Planning process is a vehicle for capturing some of those shades of gray.” Take, for example the Iris Goals and Planning Summary, which is a personalized treatment summary and addendum that goes beyond the legal directive to incorporate more of the individual’s values, concerns, goals and wishes, expressed in their own words. This document can be shared with loved ones, physicians, points of care and anyone who the individual thinks should be aware of their wishes. 

Sometimes the conversation may need to be revisited in three or six months or after there is a major change in the individual’s health or due to a recent stay in the hospital, just to see what might have changed in their attitudes since the first conversation and if documents need to be updated based on evolving preferences.  Cannizzaro acknowledges that these conversations require a sensitive  and human touch because it is not a topic that most people look forward to talking about. Iris facilitators are experts in healthcare but are also skilled at asking the kinds of questions that can put individuals at ease and help them open up and consider what might happen in the future.

“Our facilitators might say, ‘We’d like to know a little more about your medical experience so far.’ That sets the stage for the next question: ‘When you need to make big medical decisions, what are the most important things to take into consideration? Just focusing on which treatments the individual might want, given the complexities and uncertainties involved could lead to decision paralysis,” she says. “But if you talk about what’s important to the individual, the opportunities open up. If the individual has been sick for a while, this is probably not the first time they have thought of these questions. But having an expert-guided conversation can help a lot with processing, understanding and verbalizing their preferences. 

Uncovering Potential Barriers 

Another big part of having these expert-led facilitations is potentially uncovering potential barriers to realizing their care preferences. In some situations, an individual may prefer to stay at home to avoid the hospital or assisted living facilities, but is worried about being a burden, financial or otherwise, on their loved ones. “If independence is most important to me, and if certain treatments might affect my independence, I need to know that. What if I can’t walk but live on the second floor, with no way to get out? Okay, what, then, is realistic?” Cannizzaro says. “My facilitators are trained to surface these kinds of barriers in realizing the individual’s care plan. What could blow up the best-laid plans? How do you overcome these barriers?”

It’s also important to talk about other things happening in their lives including unmet needs. What is the support system or the family dynamics? “Iris doesn’t get involved in answering specific questions about your medical treatments, but we can help coach people in what to ask their doctors, she says. “And if you need a referral, for example, to a home-based palliative care support service or a prescription drug assistance program, we can help to connect with these services.”

These are just some of the added benefits that individuals receive from utilizing Iris’ Advance Care Planning Services. Our deep experience in goals of care planning allow us to provide meaningful and beneficial guidance to individuals through the full lifecycle of the Advance Care Planning process including discussion, creation, distribution and implementation of care plans. This approach creates a supportive, guided process for members to create high-quality care plans while also reducing the time-intensive, complex burden of Advance Care Planning discussions for provider physicians and care managers.

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