Advance Care Planning: Advance Directives for Health Care

As patients age and begin to see their cognitive function decline, advance care planning helps document their preferences for future medical care. However, in one survey, 92.1% of patients reported having spoken with their families about their treatment wishes for end-of-life care, but only 17.5% reported speaking with their family doctor.

Including advance care planning in a cognitive care plan ensures that patients’ medical decisions will be honored when they are unable to advocate for themselves.

In this article, we’ll cover what healthcare providers need to know about advance care planning with patients and their caregivers.

What Is Advance Care Planning?

Advance care planning is the act of discussing and preparing for future medical care when a patient is no longer able to communicate their wishes. Including health care providers in these conversations helps document preferences for medical treatments and inform care decisions.

Legal advance directive forms are only one part of advance care planning. Because medicine is always changing, the larger focus of advance care planning is discussing patients’ personal goals and values. This can help guide family members’ in making decisions during unexpected circumstances.

A 2014 study consistently showed five priorities that patients and their families wanted to include in end-of-life discussions:

• Patients care preferences

• Patient values

• Prognosis

• Fears or concerns

• Additional questions

When it comes to palliative care, relieving suffering is prioritized over aggressive treatment to prolong life. Simply giving space for patients to articulate their feelings during advance care planning improves emotional outcomes and quality of life.

Because a medical emergency can arise at any time, there is never a bad time for patients to make their wishes known. However, advance care planning becomes essential when patients first begin to display any signs of cognitive decline.

Using cognitive assessment tools like Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-SR) helps physicians determine when it’s time to broach these conversations if they haven’t begun already. 

What Are Advance Directives?

In one study, only 11.9% of surveyed patients preferred life-prolonging care, but less than half had completed an advance care plan. Advance directives provide legal documentation for patients’ wishes regarding medical interventions and when to cease treatment.

The two standard components of advance care directives are establishing a living will and naming a healthcare proxy. This sample document from the American Academy of Family Physicians is a good starting point for advance directives, but more specific details are based on individual state requirements. 

Directives will be specific based on the wishes, values, and beliefs of individual patients. For example, Jehovah’s Witnesses have their own advance directive forms to make sure their religious beliefs are honored when it comes to medical intervention.

Copies of these documents should be given to the:

• Patient

• Primary care provider

• Health care agent or proxy

• Lawyer

When new diagnoses or changes in cognitive function arise, it is valuable to review advance directives with patients to be sure their documented preferences are up to date.

Thinking Beyond Advance Directives

In the 2007 paper Controlling Death: The False Promise of Advance Directives Dr. Henry S. Perkins argues that advance directives can only go so far in end-of-life care. He says “advance care planning should emphasize not the completion of directives but the emotional preparation of patients and families for future crises.”

One major barrier in end-of-life planning is family members' or patients' difficulty accepting a poor prognosis. While legal documentation is important for future care planning, attending to emotional needs is equally important for a positive end-of-life experience.

Who Needs an Advance Care Plan? 

Every year, there are roughly 10 million new cases of dementia worldwide. However, less than 40% of dementia patients worldwide have the opportunity to make their advance care preferences known.

Providing cognitive tests for dementia helps providers:

• Identify early signs of cognitive decline

• Determine what preventative care interventions are possible

• Track patients’ progress over time

• Document patients’ treatment preferences early

By 2030, it is expected that 1 in 6 people will be over the age of 60, which will greatly increase the amount of family members taking on caregiver roles. Making plans for future medical care for dementia and Alzheimer’s patients can reduce caregiver strain and guilt around medical decisions.

What Does Advance Care Planning Include?

Advance care planning documentation includes a combination of advance directives and medical orders. While each of these elements are used to establish patients’ medical wishes, they have different functions.

• Advance directives include a living will and assigning power of attorney for healthcare. They provide guidance on medical care for patients who cannot advocate for themselves.

• Medical orders include DNR, DNI, DNH, out-of-hospital DNR, and POLST/MOLST forms. They document patient preferences for life sustaining treatment. 

While EMTs cannot honor advance directives, they can honor POLSTs and DNR orders if the documentation is on the patient’s person.

Living will

A living will is a legal document that documents a patients’ preferences for different medical treatments, as well as when they would like treatment to cease.

This advance directive typically includes patient preferences about:

• Receiving CPR

• Antibiotics or antivirals to treat infections near end-of-life

• When to turn off a pacemaker

• If and how long they consent to mechanical ventilation

• If and how long they consent to a feeding tube

• If and how long they consent to dialysis

• Palliative care including use of pain medication, invasive treatments, and the choice to die at home

• Tissue and organ donation

• Donating their bodies to science

While this documentation is important for patient wellness, unfortunately it isn’t always honored. For example, one Canadian study identified that CPR overtreatment was prevalent in 35% of patients.

Health care proxy

A health care proxy is the person a patient assigns to make medical decisions on their behalf if they are unable. This directive also has names like power of attorney or health care agent. Both the name and specific requirements of this role vary by state, and typically must not be one of the patient’s health care providers.

When creating an advance care plan with patients, discuss their options for a trustworthy health care agent. Determining this advance directive when a patient’s cognitive function is higher is helpful in making sure they assign the role to someone they trust.

DNR 

Do Not Resuscitate (DNR) orders are a key part of advance care planning, and specify whether or not a patient consents to CPR. Age is a major factor in patients’ choice to have DNR orders, with patients aged 75-85 being 50% more likely to have them, which increased to 140% more likely for patients over 85. 

DNI

Do Not Intubate (DNI) orders determine if a patient consents to being intubated and put on a ventilator. Non-invasive ventilation is still permitted for these patients, and can have positive health outcomes.

DNH

Do Not Hospitalize (DNH) orders are typically put in place for patients in nursing homes. In an emergency, these orders point to calling the family before calling an ambulance so they can make an informed decision based on the circumstances.

Out-of-hospital DNR

Depending on what state the patient is in, physician-ordered DNR bracelets or signed forms can identify if a patient would refuse CPR or advanced cardiac life support. If at any time a patient is still conscious they state that they have changed their mind, then medical intervention is permissible.

Out-of-hospital or pre-hospital DNR orders can come with their own challenges, including EMT liability and potential errors in implementation.

POLST Forms

Physician orders for life-sustaining treatment (POLST) is a prescribed, out-of-hospital medical order from a patient’s primary care provider. These forms are usually for people with severe or advanced illness, and direct medical courses of action based on what is documented in a patient’s advance directives. The details of POLST forms themselves vary by state, and are sometimes known as MOLST forms—medical orders for life-sustaining treatment.

These forms are meant to be kept visible for medical personnel. They detail permitted treatments and their conditions, as well forbidden treatments.

This can include patient preferences on:

• Resuscitation

• Hospital admission

• Emergency room transfer

• Ventilation

• Tube feeding

• Antibiotics

• Pain management

Meeting the Medicare Requirements for Advance Care Planning

Advance care planning services are reimbursable under Medicare as long as they meet a few requirements. The appointments must be voluntary and face-to-face, and can either be part of an annual wellness visit or initial preventive physical exam. In some circumstances, these discussions could also be billed as a separate Medicare Part B medically necessary service.

Required documentation

When documenting an advance care planning appointment, providers must include:

• A statement that the visit was voluntary.

• The explanation of advance directives (it is allowed, but not required, to have the forms filled out in the appointment).

• Who was present during the appointment.

• How much time was spent on advance care planning.

• Any changes in the patient’s health status

• Any changes in the patient’s medical preferences regarding advance care planning

Advance Care Planning CPT Code

Medicare-covered advance care planning can be documented under two CPT codes. These codes are for time spent discussing advance care preferences, explaining advance directives, and filling out directives.

There is one significant difference between the codes:

• CPT 99497 is for the first 30 minutes of advance care planning services.

• CPT 99498 is for every additional 30-minute unit of advance care planning services.

Physicians should determine which code to use based only on the amount of time spent on advance care planning. For example, if a health care provider spent at least 31 minutes of neuropsychological testing and then an additional half hour discussing advance care planning, they would use both CPT Code 96132 and CPT Code 99497.

Any discussions under 15 minutes can be billed under other appropriate codes.

Advance Care Planning ICD-10 Code

Along with documenting the appropriate CPT code for the appointment, health care providers should also document the appropriate ICD-10 code for the patient’s diagnosis.

For example, if a physician was discussing advance directives for a patient with dementia in Alzheimer’s disease with early onset, they would input code F00.0.

Enhancing Cognitive Care Delivery and Care Planning

Advance care planning is a common part of managing cognitive decline. Screening for and tracking patients’ cognitive function helps guide discussions between doctors, their patients, and patients’ family members.

Creyos’ neurocognitive health tools help monitor cognitive function changes related to mild cognitive impairment (MCI), dementia, and Alzheimer’s disease. Our quick questionnaires can screen for signs of MCI with greater sensitivity than standard tests, and are highly user-friendly.

Physicians benefit from our solutions that:

• Include pre-packaged materials that take 20-30 minutes to complete with patients

• Are built with Medicare requirements in mind

• Are aligned with reimbursement best practices

• Include thorough record-keeping tools

• Have easy to interpret data presentation

• Have steps for every stage of managing cognitive health care

Connect with us today to learn more about what we offer.

Collaborating On Future Medical Care

Advance care planning ensures that patients’ individual preferences for medical care will be honored even when they can no longer advocate for themselves. By having open conversations about the state of patients’ cognition, health care providers can offer patients dignity through the end of their lives.