Survey reports on barriers to advance care planning discussions
Barriers included lack of a formal system to assess patients' end-of-life wishes and goals of care, no place in an electronic health record to indicate whether a patient has an advance care plan, and little formal training in end-of-life discussions with patients and families.
Although most physicians feel that discussing advance care planning with patients is important, many are unsure of how to do so, a new survey has found.
The survey included 470 internists or other primary care clinicians, 85 oncologists, 87 pulmonologists, and 94 cardiologists. Physicians were asked their opinion of the new Centers for Medicare and Medicaid Services decision to reimburse clinicians for conversations about advance care planning, along with questions about motivations and barriers as well as billing for the service. All of the physicians in the survey saw Medicare patients, and 74% said that they cared for patients who were likely to die within a year.
Almost all of the physicians surveyed, 99%, considered it important that clinicians discuss advance care planning with patients, and 95% said they supported the new Medicare benefit, with 75% saying that the benefit made them more likely to have such conversations. In addition, 75% of respondents said they thought it was their responsibility to initiate advance care discussions. However, only 14% of respondents who had fee-for-service Medicare patients reported that they had billed for this service.
Barriers to providing the service included lack of a formal system to assess patients' end-of-life wishes and goals of care, with only 29% of clinicians reporting having such a system in place. Forty percent of respondents said that their electronic health record (EHR) has no place to indicate whether a patient has an advance care plan or that they were unsure whether it did. Of clinicians who reported that their EHR did have a place to indicate existence of an advance care plan, 31% said that they were not able to see the actual contents of the plan.
Formal training in end-of-life discussions with patients and families was reported by 29% of the clinicians surveyed. Those who had formal training were more likely to report that end-of-life conversations were rewarding rather than challenging. Forty-six percent of respondents said that they frequently or sometimes felt unsure of what to say during such conversations, while other barriers included a lack of time (66%), a sense of disagreement between the patient and family members (64%), and uncertainty about the right time to start a conversation (60%). In addition, physicians indicated that they did not want patients to feel that an advance care planning discussion meant that their physician was giving up on them (48%) or that they should give up hope (46%).
Physicians reported that their main motivations for starting advance care discussions were honoring their patients' values and wishes (92%), decreasing unnecessary or unwanted hospitalizations toward the end of life (87%), and increasing patients' and families' satisfaction with care (81%).
The nationwide survey, which was commissioned by the John A. Hartford Foundation, the California Health Foundation, and the Cambia Health Foundation, was conducted by telephone from Feb. 18 to March 7, 2016. Results were released on April 14. A press release and other materials are available online.