ACP Reimagined
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Shortly after its introduction in the late 1960s, the written living will or AD became the accepted gold standard for expressing one’s own end-of-life wishes, and the Cruzan decision allowed surrogates to provide “clear and convincing evidence” of those wishes should a written AD not exist. Completing an AD was often considered a one-time event occurring after a terminal diagnosis or at the end of life. However, many have argued against the ability of ADs alone to achieve the treatment preferences and goals of care desired by the patient.
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To accomplish the patient’s preferences and goals, ADs rely on the completion of three specific steps:
“(a) People must complete living wills [advance directives], (b) individuals must be able to express authentic and stable preferences in their living wills, and (c) surrogates must be able to understand those preferences well enough to predict the patient’s wishes accurately” (Fagerlin, Ditto, Hawkins, Schneider, & Smucker, 2002, p. 270).
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Swetz (2017) identified one criticism of ADs as inability of the “gold standard” written AD document to predict patient treatment wishes any better than discussions with physicians, patients, and surrogates that occurred before completion of the AD. Sabatino (2010) highlighted several issues with what he calls the legal transactional approach to ADs, which included low usage of legal documents, limited understanding of the documents, instability of decisions over time and health status, inability of a surrogate to correctly identify the patient’s wishes, and lack of physician knowledge regarding existence or location of such legal documents.
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Despite these challenges, Brown (2003) stated the majority of people, both healthy and sick, believe advance directives are important even though only about 1/3 actually complete written legal documentation. To address some of the concerns with ADs, practitioners and researchers have suggested a shift from the one-time advance directive document completion to a lifetime advance care planning (ACP) process. This iterative process incorporated several elements including communication between patient, physician, and surrogate regarding personal values, goals of care, treatment preferences and palliative care opportunities; surrogate decision making along with the leeway to make those decisions; and completion of advance directive documents.