For some people, it may be feasible and valuable for communication about end-of-life care to begin well before a diagnosis of incurable illness. For example, a physician with an established relationship with a patient may, during a routine medical visit, initiate a brief discussion about preferences in the event of a catastrophic illness or injury or about the identification of a surrogate decisionmaker. The advantages of early discussion may include encouraging at least basic preparations for the unexpected (e.g., signing a durable power of attorney); reinforcing the relationship between clinician and patient; and laying the foundation for later, more specific discussions (Teno and Lynn, 1996). This kind of communication may be less likely to occur when patients lack a continuing relationship with a personal physician.

Elements of Advance Care Planning

The details of advance care planning may be highly specific to patients and families, but certain general elements can be identified. These elements are not so much a matter of specific documents—although such documents can be very useful—as they are parts of an ongoing process that includes discussions with patients and those close to them about what the future may hold; what the patient and family want to achieve as life ends; what options are available—and what their potential benefits and burdens are; what preferences should guide decisions; what practical issues should be anticipated; and, depending on the circumstances, what immediate steps should be taken. In this broad sense, advance care planning provides an important basis for a cooperative effort, first, to understand people's physical, emotional, practical, and spiritual concerns; second, to prevent distressing and unwanted interventions; and, finally, to secure what the patient, family, and care team will regard as a good death.

In addition to raising a variety of practical issues and actions, those offering support may suggest that patients and families go through a values exercise to clarify what they hope for and fear. One approach to such an exercise is included in Box 3.3.

Advance care planning often includes written directives. The directives and their legal context are discussed in Chapter 7. Table 3.2 suggests the kinds of issues to be raised with patients depending on their health status, cultural backgrounds, and preferences. In general, the guidelines for communication identified earlier in Box 3.1 will apply to advance care planning discussions.

The stability of patient preferences about treatment at the end of life is an important concern but one not investigated in-depth. What might seem desirable when death is a distant, abstract possibility may be frightening when one is actually diagnosed with an eventually fatal disease. Once people

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