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Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwarranted Suffering

Joanne Lynn, MD, MA, MS; and Nathan E. Goldstein, MD
[+] Article, Author, and Disclosure Information

*Note: The California legislature has enacted AB 487, which requires all California physicians to complete 12 hours of continuing education in pain medicine and end-of-life care by December 2006. Exceptions to the requirement are physicians in the specialties of pathology and radiology. Further information can be found at http://www.medbd.ca.gov/cmelaws.htm or http://www.sfms.org/sfm/sfm202e.htm.

From The Washington Home Center for Palliative Care Studies and RAND Health, Washington, DC, and The Robert Wood Johnson Clinical Scholars Program, Yale University, New Haven, Connecticut.

*This paper was prepared by Joanne Lynn, MD, MA, MS, and Nathan Goldstein, MD, for the Quality Grand Rounds series. Sanjay Saint, MD, MPH, prepared the case for presentation. The case and discussion were presented at the Sixth Annual UCSF Management of the Hospitalized Patient Conference in San Francisco, California, on 11 October 2002.

Grant Support: Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation as part of its Quality Initiative. Dr. Lynn is supported by The Center for Patient Safety at the End of Life, which is funded by the Agency for Healthcare Research and Quality, grant 1P20HS11558-01. Dr. Goldstein is supported by the Robert Wood Johnson Foundation and the Department of Veterans Affairs.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Joanne Lynn, MD, MA, MS, Center for Palliative Care Studies, The Washington Home and Community Hospice, 4200 Wisconsin Avenue NW, 4th Floor, Washington, DC 20016; e-mail, jlynn@thewashingtonhome.org.

Current Author Addresses: Dr. Lynn: Center for Palliative Care Studies, The Washington Home and Community Hospice, 4200 Wisconsin Avenue, NW, 4th Floor, Washington, DC 20016.

Dr. Goldstein: Robert Wood Johnson Clinical Scholars Program, Yale University, IE-61 SHM, PO Box 208025, New Haven, CT 06520-8025.

Ann Intern Med. 2003;138(10):812-818. doi:10.7326/0003-4819-138-10-200305200-00009
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Patients with eventually fatal illnesses often receive routine treatments in response to health problems rather than treatments arising from planning that incorporates the patient's situation and preferences. This paper considers the case of an elderly man with advanced lung disease who had mechanical ventilation and aggressive intensive care, in part because his nursing home clinicians did not complete an advance care plan and his do-not-resuscitate order did not accompany him to the hospital. The errors that led to his hospitalization and his unwanted treatment there demonstrate how the ordinary lack of advance care planning is deleterious for patients who are nearing the end of life. We discuss serious, recurring, and generally unnoticed errors in planning for care near the end of life and possible steps toward improvement. Repairing these shortcomings will require quality improvement and system redesign efforts, methods familiar from patient safety initiatives. Reliable improvement will also require making it unacceptable for clinicians to fail to plan ahead for care during fatal chronic illness.


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Elements essential to reliable, high-quality care for patients with fatal chronic illness.
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