Everyone over the age of 18 should choose a health care proxy – someone to make medical decisions for them in case they’re ever unable to speak for themselves. Although we should all have one, many of us postpone choosing a proxy until a crisis hits. The Conversation Project, a five-year-old initiative based at IHI whose goal is to ensure that everyone’s wishes regarding end-of-life care are expressed and respected, has just published a user-friendly free resource to help: How to Choose a Health Care Proxy & How to Be a Health Care Proxy.
In addition to providing details about this guide, the April 6 WIHI (Who's Your Health Care Proxy?) featured panelists who shared their insights and tips for how to help patients pick a proxy and how to document their proxy choice in the medical record. They shared three key strategies:
- Make completing health care proxies an organizational priority - Fiona McCaughan, RN, MS, a nursing leader at Cambridge Health Alliance (CHA), noted that all of the primary care practices in the CHA safety net system routinely ask patients to choose a proxy and complete the health care proxy form. They include the proxy form in information packets for all new patients. They run reports and discuss how to address patients who haven’t yet chosen health care proxies at their daily huddles. McCaughan shared a process map that indicates that their efforts start before the patient is due for an office visit and don't end until they have recorded a proxy in their records and returned the proxy form to the patient.
- Use a team-based approach - Ravi Parikh, MD, MPP, an internal medicine resident at Brigham and Women’s Hospital in Boston (BWH), noted that research indicates that engaging a team (including administrative support staff, physician assistants, nurses, social workers, and physicians) in a standardized process can increase proxy decisions or verifications by almost 25 percent.
Parikh reported that physicians at BWH initiate discussions about advance care planning. They then refer patients who agree to complete a health care proxy to social workers trained to take them through the process. If the patient wants to have a more detailed discussion – to complete a Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, for example – the social workers refer them back to their physician.
- Incorporate health care proxy discussions into regular care - Suzanne Salamon, MD, Associate Chief, Gerontology Division, Beth Israel Deaconess Medical Center, described how she normalizes discussions about choosing a health care proxy by addressing the topic during every patient's first visit. She noted that even patients with early dementia can (and should) make such decisions before their disease progresses. (The Conversation Project's Starter Kit for Families and Loved Ones of People with Alzheimer’s Disease or Other Forms of Dementia can be a helpful guide.)
Medicare now covers physicians' time for conversations about end-of-life care. But, according to Dr. Parikh, research suggests that in 2016 fewer than 20 percent of physicians used the relevant reimbursement codes. There’s clearly room for improvement, if this is one indicator of how infrequently these discussions are happening in health care.
Find all the information from this WIHI, including slides and the audio recording, on the WIHI archive page. (You'll find a particularly rich chat discussion from this show.) Download this broadcast as a podcast by searching for “IHI” through iTunes or your favorite podcast app.