Reexamining Advance Care Planning
Chris Herman, MSW, LICSW
NASW-DC Senior Practice Associate
Advance care planning is a process that enables individuals to determine and communicate their goals for health care. Clients’ engagement in advance care planning varies widely and may be influenced by multiple factors. Such variation requires reexamination of assumptions underlying the U.S. health care paradigm. To facilitate advance care planning effectively, social workers must understand each client’s values and biopsychosocial context and tailor interventions accordingly.
Overview of Advance Care Planning
Advance care planning involves anticipating one’s health care preferences in the event a medical condition would preclude such decision making. These decisions may apply to any situation in which one is unable to make or communicate health care decisions—including, but not limited to, the end of life—and may be documented in advance directives.
Advance directives often involve two components. A living will documents the types of care one wishes to receive or forego in the event she or he loses decisional capacity. By creating a health care proxy (sometimes referred to as a power-of-attorney for health care), one may designate a n individual or individuals to make health care decisions on one’s behalf. A health care proxy does not designate authority to make financial decisions on behalf of another person, however.
Though completion of advance directives constitutes an integral component of advance care planning for many people, advance care planning is not a one-time event. Rather, completion of advance directives is but one step in an ongoing process of determining, communicating, and reassessing one’s choices for future health care (Borgmeyer, 2011; Bullock, 2011a; Peres, 2011). Similarly, advance care planning is not done in isolation. Ongoing communication with health care agents, health care providers, and other trusted individuals regarding one’s health care decisions is essential not only to effective planning, but also to reassessing and revising care goals over time and to realizing plans that have been put into place.
The Patient Self-Determination Act (PSDA) (1990) mandates that all health care institutions receiving Medicare or Medicaid funding inquire and provide information about advance directives to patients in their care. Accordingly, state statutes regarding advance directives now exist throughout the U .S. Nonetheless, advance care planning is not covered within the Medicare annual wellness visit (a benefit established by the Patient Protection and Affordable Care Act ), despite having been added to the benefit by the Centers for Medicare & Medicaid Services (CMS). The myths and political controversy surrounding the potential enactment and eventual rescindment of this provision (Clark, 2009; National Hospice and Palliative Care Organization, 2011; Pear, 2011) continues to pose challenges for end-of-life care advocates and providers—and, ultimately, for consumers.
Tips for Social Workers
Advance care planning is an ongoing process, not a one-time event.
The goal of advance care planning is to elicit and facilitate communication of clients’ values and goals. Client access to and understanding of clear, relevant information about all available health care options is integral t o informed decision making.
Self-determination may be realized not only through autonomous decision making, but also through collective or deferred decision making. Advance care planning may involve engaging multiple individuals or groups in the decision-making process.
Advance care planning behavior can only be understood within each individual’s unique biopsychosocial context. A comprehensive, culturally and linguistically competent assessment is essential to understanding how each person approaches health care decision making.
Advance directives may be expressed in both oral and written forms. Some clients may need support and encouragement to discuss their written advance directives with health care agents, other loved ones, and health care professionals; other clients may need information and support to document their choices.
Health care agents need education and support to fulfill their roles. Facilitation of communication between individuals and health care agents is an essential component of advance care planning.
Decision making cannot be equated with planning. Supporting a client’s decision-making process may mean supporting the choice not to engage in advance care planning...
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- The Value of Advance Care Planning
- Variations in Advance Care Planning Behavior
- Assumptions Underlying Advance Care Planning