Advance Care Planning Among Patients with Heart Failure: A Review of Challenges and Approaches to Better Communication

Despite these challenges, there are some studies of communication skills training courses that have demonstrated the ability to increase providers’ use of empathic and facilitative communication (eg, use of open-ended questions) [58,95], and to increase self-efficacy and confidence among providers [96]. One particular teaching model that is increasingly used in cancer care is Oncotalk (http://depts.washington.edu/oncotalk/). Oncotalk has been shown to significantly increase clinical skills in giving bad news and facilitating the transition to palliative care. Building on this success, the program has expanded to training courses focused on the intensive care setting (http://depts.washington.edu/icutalk/) and geriatrics care [97–99]. It is important to note, however, that the considerable time and resource-intensive nature of communication training programs limits widespread implementation of any one approach into routine medical education. More attention to the type and structure of communication skills training programs are needed as well as scalable approaches to assist clinicians in developing effective ACP communication skills.

Policy Implications of ACP and Future Directions

There is growing recognition of the need to improve ACP among patients with seriously illness, including heart failure. In a recent Institute of Medicine (IOM) report, Dying in America [100], the need for clinician-patient communication about ACP was identified as a primary area of improvement. Recommendations include the establishment of communication quality standards as well as guidelines promoting early and ongoing ACP discussions. This is supported by recommendations from medical professional societies for an iterative model of ACP that follows the course of a serious illness [2,101]. At early stages of the illness, ACP might be focused on helping patients clarify their broad health care values and raise awareness of their disease and expected prognosis. As the condition progresses, ACP discussion might focus on exploring disease-specific treatment options within the context of previously expressed preferences, as well as identifying changes in patients’ values over time, particularly as they gain experience with their illness and health status changes [102]. In late stages of the disease, ACP might focus on documenting specific treatment choices (eg, DNR orders) and on exploring options such as palliative care, while also ensuring that patients and caregivers are appropriately prepared for imminent decline and death.

The IOM report also calls for payment reforms to include reimbursement for outpatient ACP discussions [100]. There is burgeoning national support for developing reimbursement models for ACP discussions. The American Medical Association has recently released current procedural terminology (CPT) codes for ACP services, a first step toward urging Medicare to consider reimbursement for ACP discussions with physicians.

Finally, the IOM report calls for improved education and training in ACP communication across all disciplines and specialties providing care to patients with serious illness. These recommendations bring national attention to the current limitations surrounding ACP discussions for those with serious illness, including heart failure. Further research is needed to identify methods and care models to address the gap in communication skills, processes, and policies.

Corresponding author: Sangeeta C. Ahluwalia, Rand Corporation, 1776 Main St., Santa Monica, CA, 90401, sahluwal@rand.org.

Financial disclosures: None.

Author contributions: conception and design, SCA, SE; analysis and interpretation of data, SCA, SE; drafting of article, SCA, SE; critical revision of the article, SCA, SE.