Re: A Reflective Case Study in Family Medicine Advance Care Planning Conversations

To the Editor: Drs Tunzi and Ventres¹ have addressed the importance of discussing advance care planning (ACP) with an integrative approach. ACP conversations should be broad yet flexible, and the surrogate's inclusion in the discussion is critical. It is appropriate for family physicians to initiate an ACP dialog considering their usually close relationship with the family.

From our experience, the discussion should not be initiated based on an individual reaching 65 years of age. An ACP should be considered for all adults, and the discussion best initiated during an annual physical. We proposed several steps for a meaningful dialog in an office setting.² The physician should carefully prepare the ACP discussion: make it specific to the patient, allow adequate time, and even rehearse the methodology in approaching the issue. Emphasis should be placed on the fact that an advance directive (AD) is a legal document. It provides an individual's instructions regarding his/her future medical care and identifies the health care proxy agent. Furthermore, before the discussion, the physician should succinctly explain that ACP is a routine segment of an annual physical, and is relevant to adults of all ages.

Many factors may potentially arise during an ACP discussion.³ The physician may observe that the body language displayed demonstrates an uncomfortable attitude toward with the topic. Barriers are often raised⁴ that may be related to cultural,⁵ racial,⁶ religious,⁷ and/or gender issues.⁸ Medical procedures acceptable to the physician, may be unacceptable to the party involved. Some patients suffering a chronic illness and/or a terminal illness may nevertheless choose not to institute an AD.⁹ When a person refuses to enact an AD, the physician must respect that decision.

A family member or a close trusted friend should be considered as the proxy agent and encouraged to attend a subsequent visit. The physician should emphasize that the surrogate is guided by the patient's wishes which are clearly detailed in the AD document. The surrogate will act as the proxy agent only when a patient is incapacitated and furthermore, it is the duty of the proxy agent to ensure that the individual's directives and wishes be fulfilled.

As mentioned previously, the physician's predialog preparation is vitally important for a successful discourse. The ACP discussion both educates and explores the benefits of an AD, and further establishes that on signing the document, the individual can be confident that his/her wishes will be respected and conducted in the future.