Advance Care Planning discussed and documented in the medical record, patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (DEM) (GER, Pall Cr)
CPT4 code
Name of the Procedure:
Advance Care Planning (ACP) - Documentation without Surrogate Designation or Advance Directive (DEM) (GER, Pall Cr)
Summary
Advance Care Planning (ACP) is a process where patients discuss and document their healthcare preferences for future medical care in case they become unable to make decisions. In this documented case, the patient chose not to (or was unable to) name a surrogate decision-maker or provide an advance directive.
Purpose
Advance Care Planning aims to ensure that a patient's healthcare preferences are known and respected in situations where they cannot communicate their wishes. This involves discussing values, goals, and medical care preferences. The primary goal is to guide healthcare providers and loved ones in making decisions that align with the patient's desires.
Indications
- Chronic or serious illness that may affect the ability to make decisions in the future
- Desire to have medical care align with personal values and preferences
- Legal or ethical preparation for potential incapacity
- Planning for aging, progressive illnesses, or end-of-life care
Preparation
- Consider personal values and goals related to healthcare
- Reflect on preferences for life-sustaining treatments, pain management, and other medical interventions
- Engage in discussions with family, close friends, or healthcare providers
Procedure Description
- Initial Discussion: The healthcare provider discusses the importance of advance care planning with the patient.
- Exploration of Preferences: The patient explores and expresses their wishes regarding future medical care without committing to formal documentation.
- Documentation: Although the patient did not wish to name a surrogate or provide a detailed advance directive, the discussion is documented in the medical record.
- Ongoing Conversation: Open-ended, ongoing dialogue is encouraged, allowing for updates to the patient's wishes as circumstances change.
Duration
Typically, an ACP discussion can range from 30 minutes to an hour, but it can be longer depending on the complexity and the patient's needs.
Setting
The procedure is often performed in an outpatient clinic, hospital setting, or during a healthcare visit.
Personnel
- Primary care physician or specialist
- Nurse
- Social worker or case manager (in some instances)
Risks and Complications
- Potential for misunderstanding or miscommunication if preferences are not documented accurately
- Emotional discomfort or stress discussing end-of-life care
Benefits
- Ensures patient’s wishes are known and can guide future medical care
- Provides peace of mind for both the patient and their loved ones
- Helps prevent unnecessary or undesired treatments
Recovery
No physical recovery needed since ACP is a discussion-based procedure. Patients may need time to emotionally process the conversation and may have follow-up discussions to refine their plan.
Alternatives
- Formal Advance Directives: Legal documents like Living Wills or Durable Power of Attorney for Healthcare
- Informal Discussions: Conversations with family members without formal documentation
- Do Not Resuscitate (DNR) Orders: Specific instructions regarding resuscitation efforts which can be part of an ACP
Patient Experience
During the ACP process, the patient may feel a range of emotions from comfort to distress as they contemplate future health scenarios. The healthcare provider should offer support and compassionate guidance to ensure the patient feels heard and understood.