"You actually have to create a structure in your system to make advance care planning part of the routine of care," Hammes says. "That new system has to both prompt physicians and be designed so it's realistic in demands on physician time. The role of the physician is to initiate the conversation. That takes an additional few minutes. Then the physician can hand that work off to someone on the team who can now spend 30 or 40 or 60 minutes having that conversation with the patient and family."
Effective communication regarding end-of-life care involves a carefully constructed series of at least three conversations:
First steps: The initial conversation is called "first steps," which is held with generally healthy adults by the age of 65. The basic plan would be to complete a power of attorney for healthcare to appoint a well selected and prepared healthcare agent and indicate, for example, when a serious, permanent brain injury would be so bad that the goals of care would no longer be to extend life. The first steps can be initiated by a physician (perhaps during a routine physician exam), one of the trained facilitators, or a larger community of trained coaches from churches or other local networks.
Next steps: The "next steps" stage is initiated for adults with a progressive, life-limiting illness so that the healthcare team can determine goals of treatment in the event of complications or bad outcomes. This stage of planning is for individuals who have a serious, incurable illness and may be suffering serious complications. The goal is to undertake disease-specific planning and determine when an outcome from a complication would be so bad that the goals of care would change. The next steps phase is handled only by Gundersen's trained facilitators in consultation with the physician team.
Final steps: This last stage is for those patients whose illness has progressed to the point that death is likely within 12 months. In those cases the facilitators and physician collaborate with the patient to develop a specific plan of care for medical orders, including a physician order of life-sustaining treatment.
When the physician perceives that the patient and family are ready to have an advance care conversation, the handoff goes to a specific team of facilitators depending on the stage of planning. At Gundersen, there are 70 active first steps facilitators, 10 next steps facilitators, and five last steps facilitators.
The staged approach allows each phase in the advance care plan to be discussed at a time that is most appropriate, says Carol Berra, RN, the lead next steps facilitator. These next steps conversations, she says, are discussions that involve at least three people: the patient, the facilitator, and "the primary agent," a friend or family member who has been designated by the patient to make medical choices for them.