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Massachusetts Medical Society's Physician Focus

August 2014

End-of-Life Care:
Advance Care Planning


  • Advance care planning is the process of making difficult decisions about health care that will take effect toward the end of life. It begins with conversation.

  • Among the steps of advance care planning are the completion of such forms as a health care proxy and medical orders for life-sustaining treatment.

  • Research indicates that 75% of people hospitalized with a critical illness cannot make their wishes known at that time, underlining the importance of advance care planning.

  • Advance care planning can ensure that your wishes are fulfilled, avoid family turmoil, and provide for a peaceful passing.

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A physician’s primary purpose is to promote wellness, cure illness, and preserve and protect life. Yet death for everyone is inevitable, and physicians are increasingly recognizing the importance of advance care planning – a term describing the preparation for the end of life.

Eric Reines, M.D., a geriatrician with Element Care in Lynn, Massachusetts, describes it as part of the normal routine of thinking ahead. “We’re always planning ahead for our future,” he says, citing such actions as creating a will, buying life insurance, or establishing a retirement account. “This is another part of it, the medical part, because some day something is going to happen.”

Dr. Reines, chair of the Massachusetts Medical Society’s Committee on Geriatric Medicine, joined fellow committee member Beth Warner, D.O., C.M.D., a consultant geriatrician with Cooley Dickinson Health Care in Northampton, on the August edition of Physician Focus to discuss advance care planning, what it includes, why it’s important, and how to go about it. Hosting this edition is primary care physician Bruce Karlin, M.D.

So exactly what is advance care planning?

“Advance care planning,” says Dr. Warner, “is the catch-all term for the planning we do as our health care becomes complicated and as we need to navigate challenging decisions often towards the end of life.”

Planning starts, she notes, with the simple art of talking – talking with one’s health care provider and family members to make your wishes known about end-of-life issues and to ensure that those wishes are carried out.

After those decisions are made, patients turn to completing certain forms, to specify what their wishes are. A health care proxy indicates which person you choose to make health care decisions on your behalf, should you become unable to do so, and a MOLST form - medical orders for life-sustaining treatment – outlines your preferences for such areas as whether or not you wish to be resuscitated in certain situations. Copies of such forms should be held by family members and health care providers.

Advance care planning isn’t recommended just for elderly patients or those with terminal illnesses. The physicians agree the planning and conversation should start earlier rather than later, because of the uncertainty of when that final moment might arrive.

In addition to discussion and planning, end-of-life care may also entail palliative care and hospice care. Palliative care refers to the type of care that is delivered when someone is diagnosed with a life-limiting illness. Hospice care is care for those entering the last few months of life, usually with a prognosis of six months or less.

Yet given their education, training, and primary purpose to sustain life, are physicians good at talking with patients about advance care planning?

“Physicians are getting better at this,” says Dr. Warner. “Many were not trained to have these discussions, so it’s a stepping back for most doctors, thinking about the big picture, and helping people plan for those big decisions.” Both physicians are encouraged that more of their colleagues are acknowledging the importance of advance care planning and that more patients are motivated to talk about end-of-life issues.

Getting the conversation started is the important first step, and getting it started early is important. Not only will that make your wishes known, but it has benefits for family members as well.

“Having conversations earlier and letting your family know what you want in these very serious circumstances really takes the burden off of loved ones,” Dr. Warner says.

“Health care can get complicated,” she notes, “especially as we accumulate more illnesses and get frailer. We need to think about what we want, what’s most important, and then we need to communicate that with the health care team.”

Dr. Reines recognizes the persistent hope patients can have, and the role physicians can play in their end-of-life care. “Patients facing terminal illness,” he says, “tell me ‘I’m praying for a miracle.’ I tell them I believe in miracles, too. I believe in the miracle of dignity, of comfort, of love, of peace. If you work together with your health care team, we want to make those miracles happen.”

Dr. Warner’s message to patients is also direct. “Health care providers are there,” she says. “Please talk to us. If we don’t open the conversation, and there are thing on your mind, ask.”

Watch the above video for more conversation on advance care planning, the keys steps involved, and how patients and physicians can come together to discuss and plan for end-of-life issues.

MMS/Richard Gulla

Massachusetts Medical Society

The Conversation Project

Massachusetts Medical Orders for Life-Sustaining Treatment

Hospice & Palliative Care Federation of Massachusetts

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"Advance Care Planning" PSA

From left, Bruce Karlin, M.D., Eric Reines, M.D. , Beth Warner, D.O.
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