Incorporating advance care planning into family practice [see comment]

Despite widespread support for the concept of advance care planning, few Americans have a living will or a health care proxy. Advance care planning offers the patient the opportunity to have an ongoing dialog with his or her relatives and family physician regarding choices for care at the end of life. Ultimately, advance care planning is designed to clarify the patient's questions, fears and values, and thus improve the patient's well-being by reducing the frequency and magnitude of overtreatment and undertreatment as defined by the patient. An advance directive consists of oral and written instructions about a person's future medical care in the event he or she becomes unable to communicate. There are two types of advance directives: a living will and a health care power of attorney. Family physicians are in an ideal position to discuss advance care plans with their patients. By introducing the subject during a routine office visit, physicians can facilitate a structured discussion of the patient's wishes for end-of-life care. At the next visit, further discussion can include the patient and his or her proxy. A document that clearly delineates the patient's wishes is then developed. The patient should be assured that the directive can be changed at any time according to the patient's wishes. The advance care plan should be reviewed periodically to make sure the specifications continue to be in line with the patient's wishes.