Advance Care Plan

Measure Specification

Advance care planning is a continuous process of conversation and documentation to align a patient’s care and interventions with their beliefs, values and preferences, in the event they become unable to make those decisions. The Centers for Medicare & Medicaid Services (CMS) describe advance care planning as a face-to-face service to discuss a patient’s health wishes that may or may not include completing relevant documentation (Centers for Medicare & Medicaid Services (CMS), 2019).

A number of documents may be completed as a result of the advance care planning conversation in order to capture a patient’s wishes and goals for care. These documents are generally referred to as “advance directives” and can include: Durable Power of Attorney for Health Care (DPAHC), living will, and combined directives. In addition to these documents, a patient may have a Physician Orders for Life-Sustaining Treatment (POLST), also referred to as Medical Orders for Scope of Treatment (MOLST).

A patient may also identify a surrogate decision maker to serve as their representative and decision maker in the event they cannot make decisions for themselves. Although it is widely agreed that advance care planning is a critical part of patient care, only about 50% of older adults have engaged in advance care planning. Of those older adults, about one-third have documented their wishes and only 10%–20% discussed their wishes with clinicians;.

A 2017 study found that 70% of providers indicated they only have advance care planning conversations with their patients experiencing advanced illness. The benefits of advance care planning may only be realized if the care team has access to and follows the patient’s advance care plan. Advance care planning can lead to decreased psychological distress and hospitalizations as well as improved end-of-life care, increased trust in providers and improved quality of life, and can facilitate hope.

It has also been associated with increased knowledge about treatment options, documentation of advance care planning, patient-surrogate congruence, goal concordant care and compliance with patient wishes, among others;;;.

Advance directives are designed to respect patient’s autonomy and determine his/her wishes about future life- sustaining medical treatment if unable to indicate wishes. Key interventions and treatment decisions to include in advance directives are: resuscitation procedures, mechanical respiration, chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood products, transfusions, and intentional deep sedation.

Oral statements: Conversations with relatives, friends, and clinicians are most common form; should be thoroughly documented in medical record for later reference. Properly verified oral statements carry same ethical and legal weight as those recorded in writing. Instructional advance directives (DNR orders, living wills): Written instructions regarding the initiation, continuation, withholding, or withdrawal of particular forms of life- sustaining medical treatment.

May be revoked or altered at any time by the patient. Clinicians who comply with such directives are provided legal immunity for such actions. Durable power of attorney for health care or health care proxy: A written document that enables a capable person to appoint someone else to make future medical treatment choices for him or her in the event of decisional incapacity.

(AGS) The National Hospice and Palliative Care Organization provides the Caring Connection web site, which provides resources and information on end-of-life care, including a national repository of state-by-state advance directives.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient for the performance period. The most advantageous quality data code (QCD) will be used if the measure is submitted more than once.