Advance Care Planning (ACP) & End-of-Life Planning
Two CPT codes are used to report ACP services: 99497 and 99498.
Advance directives include the following four elements
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Advance directives – spells out what you will want to be done in case you don’t have the capacity to make decisions
POLST = Physician Ordered Life-Sustaining Treatment. DNAR will be in POLST.
Other Important terminology in End of Life Planning
- Durable power of attorney for healthcare.
- Durable power of attorney.
- Instructional directive. This is an explicit instruction for how future care should be provided. The most commonly used forms of instructional directives are the Living Will and DNR/DNI/do not hospitalize orders.
- Living Will (This
- DNR/DNI
- MOLST / POLST (Medical/Provider Orders for Life-sustaining Treatment).
- Healthcare proxy (You don’t need an attorney for this. You need an attorney for durable power of attorney).
- Advance directive
- Hospice
- Palliative Care
- Capacity and Competence.
Durable Power of attorney for Healthcare.
Durable Power of attorney for Finances.
The will is usually part of a trust. Dr. Cohen recommends getting a lawyer to do your trust, which will include the will. He has done his trust including his choice to be cremated and where to spread his ashes.
Important links
- California POLST /MOLST form.
- Advance Directives handout at a clinic I worked at.
- Advance Directive Form from UCR. (Source: http://studenthealth.ucr.edu/forms/index-1.html)
- Advance Directive Forms by state. From uslwr.com/formslist.shtm
Application Question
#1: You have a patient who is brain dead and is on a ventilator. No family members, no written advance directives. A friend tells you that in several different conversations he made known to him that if his chances of recovery were slim, he would not like to be kept on life support.
What should you do? Believe the friend and take the patient off life support.
The most common form of advance directive is a patient’s conversations with relatives and friends, and these carry the same ethical and legal weight as written directives.
#2: On several occasions, a patient the patient verbalized to you (her doctor) her desire to not be subjected to life-prolonging treatments should she ever be rendered incapacitated but she declined your suggestion that she confirm this in writing. She is admitted with a massive stroke and your neurology consultant tells you that her condition is terminal and irreversible. You put the patient on DNAR and supportive care but a family member opposes this decision and wants “everything” done. What should you do? The patient’s verbal wishes to you are as good as written down. The doctor is ethically bound to follow them. You should continue DNAR and supportive care but find a way to make peace with the family member to come to a conclusion that honors the patient.
Helpful Video
Nice Video from NIH.gov (https://www.nia.nih.gov/health/advance-care-planning-healthcare-directives)
Further Reading / References
Am Fam Physician. 2012 Mar 1;85(5):461-466. Implementing Advance Directives in Office Practice. https://www.aafp.org/afp/2012/0301/p461.html
https://www.aafp.org/practice-management/payment/coding/acp.html
Am Fam Physician. 2015 Apr 1;91(7):480-484. Advance Directives: Navigating Conflicts Between Expressed Wishes and Best Interests. https://www.aafp.org/afp/2015/0401/p480.html
https://www.nia.nih.gov/health/advance-care-planning-healthcare-directives
https://www.nia.nih.gov/health/publication/end-life-helping-comfort-and-care/planning-end-life-care-decisions