Episode #114: Everything You Need to Know About Advanced Care Planning

Welcome to the Real Deal NP Club. Whether you’re hoping to become a real deal nurse practitioner or you already are one, this is the place for you to get the resources you need as you tackle this massive transition into practice. We’re your hosts, Sarah Michelle, Chief Nursing Officer of Blueprint Test Prep, and Anna Miller, Director of Nursing Content. And we’re here to hang out with you each week like your best friends in the NP space. Let’s dive in. 

Sarah: As always, hello my friends. Today we are going to be talking about a topic especially for those of you that are getting ready to head out into real deal NP practice. And so this episode is going to be all about advanced care planning and how to approach those difficult conversations as a novice nurse practitioner. 

I think sometimes this can feel a little overwhelming and intimidating. I know it was for me. Maybe you’re just really not sure how to even start these conversations, we’re kind of all in the same boat when we’re new. But that’s totally okay, we’re going to walk you through it in this episode. 

Anna: Yeah, I’m really excited to get started into this podcast because I remember learning about advanced care planning in school, but once I started out as a new NP, I just still didn’t feel quite ready to discuss it with patients. So we are going to talk about what advanced care planning is, what those legal and ethical considerations we always have to be aware of, and offer some just helpful resources and tips that you can check out for more information. 

So as always, let’s start with the basics. Sarah, what is advanced care planning? 

Sarah: It’s really just exactly what it sounds like. You are planning in advance for the care that you want. So having a plan in place is essential if you ever become just so seriously ill that you’re unable to advocate for yourself and your wants. And it’s important that patients are having these conversations with their loved ones as well, who may be helping providers make decisions on their behalf, as well as with their providers too. 

Anna: Yeah, exactly. And for those who are in primary care specifically, you might be thinking, well, how is a primary care provider going to be helpful at the bedside when someone might really need that end-of-life care? But the role of the primary care provider, including nurse practitioners, is to have these important conversations with patients. 

You want the patient to think about what their wishes would be before they are faced with a serious illness. And the primary care provider can help patients have those conversations with family members as well, like you mentioned, Sarah. 

Sarah: Yeah, I think that’s really what we want to focus on today, our role as primary care, real deal NPs. You know, we really need to keep the door open to these conversations, and ways that we can do that are just to normalize it. 

It might take several attempts to get a patient to be ready to talk about it, but just approach it as, you know, this is something I talk to all of my patients about, especially while they’re in good health. But I would like to hear your thoughts on what would be most important to you should you need life-saving treatment. Is your priority to receive aggressive treatments if necessary, or do you want the focus to be comfort? And it can really be as simple as that. 

Anna: Yeah, and like you said, it may take several attempts. So it’s important to keep approaching the topic in a non-threatening way and to use terms that are easy to understand. And I also love that you said to the patient, you have these discussions with all of your patients, because again, that helps to normalize it. 

Another thing you can do is just acknowledge that this may be a scary idea to think about, but you as their provider want to help make sure that their wishes are followed when it matters most. 

Sarah: And please remember too, this is a continuous process. Just as it may take several visits to have a complete conversation with a patient about that advanced care planning, you should also be updating your records at least once a year too. And this is important because someone in their 30s or 40s might want that more aggressive treatment. But as they age and things change, their wishes may change too more towards palliative care. 

Conversely, we don’t want to assume that as people age that they want less treatment. So if someone in their 80s wants all the treatment possible, then we should be having those discussions with them about what exactly that entails. 

Anna: Yes, definitely. And one more thing I want to add here is that you can bill for your time spent on advanced care planning. You need to spend a minimum of 15 minutes on the discussion with your patient, but if you are taking the time during a visit, you can bill for your time and receive a reimbursement for that time spent. So if you are in an office where you will be participating in advanced care planning, definitely reach out to your billing and coding specialist or your office manager for more information on those CPT codes. 

Sarah: Yes, and thanks for that reminder, Anna. 

Now I think we should talk about some of the legal considerations to be aware of. Because yes, advanced care planning is more about the conversation, but legally it comes down to those advanced directives. 

So advanced directives are those legal documents to outline the care that someone wants to receive if they can no longer communicate their wishes. And the two main types of advanced directives are living wills and power of attorney. So Anna, can you kind of talk about living wills first? 

Anna: Yeah, sure. Living wills outline a patient’s wishes for specific treatments. So they can be as specific as outlining a patient’s preference for CPR, tube feedings, ventilatory support, pain control, chemotherapy, even dialysis. 

Now, living wills, they cannot cover every single possibility. And really, they’re mostly reserved to be used in the event that a patient becomes severely incapacitated. Living wills are most helpful for family members when needing to make decisions on the patient’s behalf. 

Sarah: So then let’s also compare that to a power of attorney. So the document known as a durable power of attorney grants power to someone that is designated by the patient to make decisions for the patient should they be unable to make them for themselves. So most often a spouse or a legal partner will be that designated decision maker in the absence of another designee. 

But some patients may choose to have another person be their decision maker for them, which is 1000% okay. And people can have different designees for medical decisions and financial decisions. So there is flexibility here too. 

Anna: Yeah. And one other type of legal document I want to bring up is the physician orders for life sustaining treatment or a POLST. A POLST is like a set of portable medical orders. And although physician is in the title of the document in most states, an NP or a PA can also sign them. And a POLST is a unique form in that it provides signed orders for emergency personnel, such as paramedics and emergency department staff to follow during a health crisis. 

So this form also includes sections on a patient’s wishes for CPR, intensity of medical intervention including ventilation, antibiotics, artificial hydration, and nutrition. 

Sarah: I like to think of it really as a compliment to an advanced directive, like a living will, in that it provides a succinct way for emergency personnel to follow up a patient’s wishes, especially since it is an order signed by a provider. 

And, of course, alongside all of this, we have ethical considerations when we’re talking about advanced care planning. A common question is if providers can override a living will. And the answer is actually sometimes. Most times healthcare providers will try to honor a patient’s wishes, but there may be instances where it is more ethical to go against a living will or that POLST form or if the advanced directive completely goes against the standard of care. But these are not the norm, these are the exceptions. 

Anna: Yes. Yes, great point there. Definitely the rare exception. And as nurse practitioners, I think we just really need to evaluate our own biases. Like what are our own thoughts about life sustaining treatment versus palliative care? What would we think about following a patient’s wishes for not wanting CPR or declining artificial nutrition or IV hydration? 

And then think about how you would present these different options to your patients during advanced care planning conversations. 

Sarah: Exactly. And, you know, maybe even just practice having some of these conversations with your friends and your family. Like how would you describe the process of CPR? For example, if we describe CPR in a way that’s overly traumatic and brutal, that alone is likely going to dissuade someone. And the opposite is true too. If we talk about CPR in a nonchalant way, no big deal, we may be unknowingly convincing more patients to agree with it that otherwise wouldn’t if we were transparent and honest and open about it. 

Anna: Yeah, 100%. We definitely need to look at how we are presenting these things. I remember one patient I gave CPR to, a few days later I was talking to her and she was like, “Hey, you didn’t break any of my ribs.” But just presenting both sides of it and being very neutral is going to be really helpful. 

And having practice conversations is just a great way to learn how to navigate the topic while also being an advocate for your family and friends wishes. 

Sarah: Yeah, and I think I would really kind of like to round out this conversation today by talking about just some resources available to y’all. 

So as a new nurse practitioner, you might still have a lot of questions about advanced care planning, or maybe you want some information to share with patients. And so two resources for patients that you can share with them are The Conversation Project found at theconversationproject.org, and Prepare For Your Care found at prepareforyourcare.org/welcome. And both of these websites discuss advanced care planning in terms that are super easy to understand. 

Anna: Yeah, and then for providers, the Centers for Medicare and Medicaid Services or CMS has a really great fact sheet that goes over important points to remember and more information on that billing and coding like I mentioned. 

Sarah: Yes. And you know, we just spent this whole episode talking about advanced care planning and how you as a real deal nurse practitioner can start to have these conversations with patients, but make sure that you are utilizing these resources as well as you navigate this time in your career. 

Anna: Yeah, and hopefully you just have a little bit of a better understanding on what this is and what the considerations to be aware of are. And now you can get started with some helpful resources that you can check out and just have those practice conversations. 

Sarah: Yeah, absolutely. And that ties it up for advanced care planning, and we’ll be talking to you all soon. 

As an extra bonus friends, if you’re looking for support no matter what phase of your nurse practitioner journey that you’re currently in, I have communities available for both students and new nurse practitioners. In these communities, we work to uplift one another and grow this profession together every single day. Links to join will be included for you in the show notes. 

Thanks for listening to the Real Deal Nurse Practitioner Club. If you want more information about the different types of support that we offer to students and new nurse practitioners, you can visit npreviews, with an S, dot com. We’ll see you next week.