Strategic targeting of advance care planning interventions: the Goldilocks phenomenon.
Strategically selecting patients for discussions and documentation about limiting life-sustaining treatments-choosing the right time along the end-of-life trajectory for such an intervention and identifying patients at high risk of facing end-of-life decisions-can have a profound impact on the value of advance care planning (ACP) efforts. Timing is important because the completion of an advance directive (AD) too far from or too close to the time of death can lead to end-of-life decisions that do not optimally reflect the patient's values, goals, and preferences: a poorly chosen target patient population that is unlikely to need an AD in the near future may lead to patients making unrealistic, hypothetical choices, while assessing preferences in the emergency department or hospital in the face of a calamity is notoriously inadequate. Because much of the currently studied ACP efforts have led to a disappointingly small proportion of patients eventually benefitting from an AD, careful targeting of the intervention should also improve the efficacy of such projects. A key to optimal timing and strategic selection of target patients for an ACP program is prognostication, and we briefly highlight prognostication tools and studies that may point us toward high-value AD interventions.
Cambridge Health Alliance, Boston, Massachusetts2Massachusetts General Hospital, Boston6Harvard Medical School Center for Palliative Care, Boston, Massachusetts.
J Andrew
JA
Billings
The Dana Farber Cancer Center, Department of Psychosocial Oncology and Palliative Care, Boston, Massachusetts4Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts5Ariadne Labs, Boston, Massachusetts6Harvard Medical School Center for Pall.
Rachelle
R
Bernacki
D032722:Advance Care Planning; D003142:Communication; D003657:Decision Making; D006801:Humans; D017060:Patient Satisfaction; D018579:Patient Selection; D010817:Physician-Patient Relations; D013997:Time Factors