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FRIENDS

A Communication Guide for Advance Care Planning
      To The Editor:
      We propose a user-friendly communication tool to guide and routinize Advance Care Planning (ACP) discussions with patients in any care setting. ACP empowers patients to communicate their preferences for medical care in case they become incapacitated. ACP decreases stress for surrogate decision makers,
      • Hickman Jr., R.L.
      • Pinto M.D.
      Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill.
      reduces health care costs, and produces positive outcomes at both patient and systems levels.
      • Jimenez G.
      • Tan W.S.
      • Virk A.K.
      • Low C.K.
      • Car J.
      • Ho A.H.Y.
      Overview of systematic reviews of advance care planning: summary of evidence and global lessons.
      However, a national survey
      • Fulmer T.
      Talking With Patients About End-of-Life Care: New Poll Reveals How Physicians Really Feel.
      found that almost half (46%) of physicians felt unsure of what to say and less than one third reported having any end-of-life conversation training. Now that Medicare requires its beneficiaries be offered ACP services routinely, it is critical for physicians to get comfortable having these discussions. We propose FRIENDS as a communication tool to train clinicians on ACP discussions.
      1. Familiarize yourself with advance directives forms: An Advance Directive (AD) is the documentation of decisions generated from ACP discussions. Clinicians must educate themselves on different types of ADs, as laws and documentation required vary by state (Table).
      TableFRIENDS Mnemonic Communication Guide for Discussing Advance Care Planning (ACP)
      Familiarize yourself with advance directives formsLearn about the laws pertaining to the documentation of ACP in your state and how those laws are applied in your health system.
      Routinize the conversationACP as a standard and routine part of your clinical practice will increase clinician and patient comfort with the conversation.
      Introduce topic; Inquire about past experiences“As part of the routine care of all of my patients, I like to take some time to discuss advance care planning and health care proxies. Are you familiar with a Health Care Proxy?”
      Elicit Preferences/Goals/Values; Expect Emotions; Explore “tell me more”“What is most important to you?” “What do you consider to be good quality of life?” “How do you find support when you are having difficulty in your life?” “Could you imagine a situation that would be a fate worse than death?”

      “Tell me more…” [….about what happened with your mother…. about how your family came to that decision….about how that experience has affected your wishes for your own care]”

      Take care to avoid certain commonly used phrases that are open to misinterpretation such as “Do you want us to do everything?” Rarely will you encounter a patient who does not want “everything,” as “everything” implies good care. How does each patient define “everything”? Does it mean all treatments necessary to prolong life, regardless of suffering, or does it mean maximal treatment of symptoms for comfort? Taking the time to clarify and explore patients' statements will prevent confusion in the future.
      Name a Health Care Proxy (or 2)Whom do you trust most in the world? Whom would you trust to be your voice in making medical decisions if you were ever in a situation in which you were unable to do so for yourself?” “Do you have someone who could serve as your HCP?”
      DocumentationClearly document ACP conversations in the medical records. Also, document the patient’s proxy and wishes, and ensure documents will be easily accessible to the HCP and clinicians in case of an emergency. Encourage patients to take a picture or e-mail a copy of the HCP to themselves, so they have easy access if they so choose.
      Summarize (Closing the Conversation. Thank you for sharing)“What do you plan to tell your [proxy, spouse, child] about what we discussed today?”

      “Thank you very much for sharing your wishes and values with me today. This conversation will ensure that we can continue to provide you with the best care possible.”
      2. Routinize the conversation: ACP discussions should be a routine part of the clinical encounter regardless of the patient’s age or stage of illness. This normalizes the process for both the patient and clinician. Patients’ wishes may change over time, necessitating ACP as an ongoing process.
      3. Introduce topic; inquire about past experiences: Introducing ACP begins with exploring the patient’s understanding of the topic (Table). Inquiring about previous experiences with family or friends who suffered serious illness may be a good way to transition to wishes regarding their own preferences.
      4. Elicit and Explore Preferences/Goals/Values; Expect Emotions: When clinicians understand their patients’ values, goals, and preferences, they are better positioned to make medical recommendations about interventions. If emotions run high, acknowledge the emotion, and explore with the patient whether the conversation should continue or be revisited on a subsequent visit.
      5. Name a Health Care Proxy (HCP): Designating an HCP is important. Patients should be encouraged to name both a primary HCP and an alternate, with the HCP present if possible. With cases in which the patient has nobody to appoint as HCP, it is critical for the clinician to document the patient’s preferences in the medical record.
      6. Documentation: Clinicians should document ACP conversations in 2 ways: Document details of the ACP conversation in the medical record, in a way that can be easily accessed, and document designation of an HCP with reliable contact information and patient preferences on the legally appropriate forms. Copies of the HCP form need to be provided to the patient, the proxy, and kept on file.
      7. Summarize: The clinician and patient should review what was discussed, using a “teach-back” strategy to verify the patient’s understanding (Table). Expressing appreciation to the patient for sharing emotional information may strengthen the physician–patient relationship and facilitate future exploration.
      FRIENDS is not a rigid checklist. It can be used to train clinicians through key steps and provide recommendations for conducting meaningful conversations. For those interested in further training, we recommend looking for opportunities to attend interactive communication workshops and exploring online resources.
      VitalTalk.

      References

        • Hickman Jr., R.L.
        • Pinto M.D.
        Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill.
        J Clin Nurs. 2014; 23: 756-765
        • Jimenez G.
        • Tan W.S.
        • Virk A.K.
        • Low C.K.
        • Car J.
        • Ho A.H.Y.
        Overview of systematic reviews of advance care planning: summary of evidence and global lessons.
        J Pain Symptom Manage. 2018; 56: 436-459
        • Fulmer T.
        Talking With Patients About End-of-Life Care: New Poll Reveals How Physicians Really Feel.
        (April 14, 2016.)
        • Annual Wellness Visit
        Medicare Learning Network.
      1. VitalTalk.
        https://www.vitaltalk.org/clinicians/
        Date accessed: July 5, 2019