Advance Care Planning Among Patients with Heart Failure: A Review of Challenges and Approaches to Better Communication

Challenges to ACP Communication in Heart Failure

Despite patient and caregiver preferences for ACP communication with their providers, evidence suggests such communication occurs infrequently [40,45] and that heart failure patients may lack important information about their prognosis and treatment options [40,44,46,47]. For example, patients may not recognize the terminal nature of heart failure, and may be unaware of the range of treatment options, including hospice, available to them. Evidence also demonstrates that ACP is infrequently discussed with their health care providers [40], resulting in these conversations being avoided or deferred until an emergent clinical situation [44,48] when hasty questions about treatment choices may yield uncertain and conflicting answers not representative of a patient’s underlying values.

The infrequent, late, and often lack of discussions about ACP are driven by several challenges. First, the uncertain trajectory of heart failure makes communication regarding “what to expect” difficult. Prognostication is an immense challenge in heart failure [40,49–52], making it harder to talk about end-of-life issues and hindering the ability of patients, caregivers and health care providers to plan and prepare for the future. It is often difficult for clinicians, who face the challenge of instilling hope in the face of truthful disclosure [53], to identify the “right time” to initiate such discussions.

Second, a lack of time, particularly during outpatient visits, impedes physician ability to have considered discussions about future care needs and preferences [32,54]. The U.S. health care system currently lacks financial reimbursement for these discussions, which poses a significant barrier to the integration of ACP conversations into routine clinical practice. Moreover, these conversations are lengthy and iterative [53]. ACP discussions that are focused on facilitating patient-centered decision-making ideally begin with a discussion of expected prognosis, followed by an exploration of patient preferences and values for health care, and then a review of treatment options to be considered in the context of those preferences. Often additional time is needed for completing advance directive documents or for charting key outcomes from these discussions. Clinicians today are frequently overloaded with addressing multiple medical issues during outpatient visits that leave little time for non-medical tasks such as ACP discussions. The lack of financial incentives to support in-depth discussions is a critical challenge in improving ACP.

Third, a lack of training in specialized communication skills, particularly focused on empathic and emotionally sensitive disclosure, may further hinder physicians from initiating frank discussions with their patients. ACP conversations are highly sensitive and fraught with emotional complexity, and clinicians understandably experience discomfort with breaking bad news [49,51,55] or with broader issues of decline and death [51,56,57]. Physicians tend to be most comfortable addressing cognitive aspects of communication; addressing the emotional needs of patients is harder. Medical school training teaches detachment in physician practice, perhaps as a way of coping with the sadness they regularly confront and in maintaining their ability to provide clinical care. In fact, physicians describe their most difficult encounters as those with the most negative expressed emotions and miss opportunities to respond with empathy [58–60], a critical skill in effective patient-physician communication that is associated with improved patient satisfaction [61,62]. While patients value good communication skills in their health care encounters, many providers feel they lack the necessary skills to lead effective ACP discussions [49,63].