Navigating health care decisions during a crisis can be overwhelming, especially for home-based care patients and their families who may be uncertain about their loved ones’ preferences. Advance Care Planning (ACP) offers a structured approach to ensure that individuals can make informed decisions about their medical care, providing clarity and reducing uncertainty for both patients and caregivers.
For the person receiving care, ACP means having a say in treatments, interventions and care preferences, ensuring their values and goals guide medical decisions. For families, ACP alleviates the burden of making difficult decisions during stressful times by providing clear directives about their loved one’s wishes.
ACP facilitates meaningful discussions between patients, their families and health care professionals to document preferences in legally recognized medical directives. This proactive approach not only enhances patient autonomy but also helps create a health care system that is more responsive to individual needs. By incorporating ACP into home and primary care settings, patients receive care that aligns with their personal values, leading to improved satisfaction and better health outcomes.
Strengthening Patient-Centered End-of-Life Care
Investing in high-quality patient-centered end-of-life care planning has shown significant benefits. When primary care physicians collaborate with palliative care specialists, patients experience improved support, greater comfort and a more efficient allocation of health care resources. This integration ensures that individuals in home care settings receive compassionate care that respects their autonomy and dignity.
Research published in the journal BMJ Supportive and Palliative Care found that seriously ill individuals who participated in ACP had a 16% higher one-year survival rate compared to those who did not. Similarly, a study from The New England Journal of Medicine revealed that patients receiving early palliative care, which includes ACP, lived 30% longer on average while being 64% less likely to receive aggressive treatments.
ACP plays a crucial role in reducing unnecessary medical interventions. Research shows that individuals who engage in ACP discussions are less likely to undergo aggressive treatments that do not improve their quality of life. Instead, they receive care that is aligned with their expressed wishes, allowing health care resources to be utilized more effectively.
ACP has also been shown to significantly reduce health care costs by preventing unnecessary treatments that do not align with a patient’s care goals. According to the National Academy of Medicine, unnecessary medical interventions contribute to $270 billion in annual health care waste. A study from the Journal of Palliative Medicine found that adjusted care costs were $9,500 lower for individuals who participated in ACP than for those who did not.
To strengthen patient-centered end-of-life care, ACP discussions should occur early and be revisited regularly. As patients’ health conditions or personal perspectives evolve, updating care preferences ensures that medical decisions remain aligned with their current wishes. This ongoing dialogue helps prevent last-minute decisions that may not reflect a patient’s true wishes.
Empowering Patients & Clinicians Through Advance Care Planning
Beyond enhancing individual experiences, advance care planning conversations contribute to the overall efficiency of the health care system. Studies suggest that structured ACP initiatives reduce hospital admissions and emergency care utilization. Patients who participate in end-of-life planning discussions are more likely to avoid unnecessary hospitalizations, intensive treatments or long-term stays in skilled nursing facilities.
“You know, this is not often a comfortable or exciting topic to discuss, but a very important and necessary one,” Dr. Joel Ramirez, chief medical officer at Camarena Health, California, said. “Aledade, with this (advanced care planning) program, helps to provide conversations in a guided manner so that patients can really have their unique goals and care preferences attended to for when that time comes they may be unable to make those decisions for themselves.”
"There have been a lot of positive outcomes by utilizing the advance care planning program,” added Camarena Health Chief Quality and Compliance Officer Leonor Seiler. “There is a lot of education in that because it's a hard topic to address."
By educating individuals about disease progression and treatment options, ACP empowers patients to create care plans that align with their quality-of-life goals. A study published in the Journal of the American Geriatrics Society found that this education significantly reduces decisional conflict, helping patients make informed and confident decisions.
One patient shared their perspective on ACP, saying: “I’m sitting here thinking, wow I made all my decisions. This is how I want it. And they’re all my decisions! Now I have a plan. It’s very helpful to know that my doctors and my family will all know my wishes. It’s just good to know that when something does happen, it’s going to be devastating enough for my family, but they won’t have to make these decisions. This just takes that worry away.”
Documenting and sharing ACP decisions ensures that care preferences are respected throughout a patient’s health care journey. This structured approach also supports caregivers by providing clear guidance on medical decisions, minimizing the emotional and logistical burdens they may face during a health crisis. Family members often struggle with uncertainty when making care decisions on behalf of a loved one. ACP reduces ambiguity, enabling families to navigate these difficult situations with confidence.
By ensuring individuals receive only the care they want, ACP benefits patients, families, and health care providers alike, fostering a more effective and compassionate health care system.
Expanding Access to Advance Care Planning
Despite its clear advantages, ACP remains underutilized, particularly among underserved communities. Many individuals are unaware of its benefits or lack opportunities to engage in these critical discussions with their health care providers. Expanding access to ACP through community outreach, education campaigns and policy initiatives can help bridge this gap.
One way to increase participation in ACP is by integrating it into routine health care visits. By incorporating ACP discussions into annual wellness exams or chronic disease management appointments, physicians can normalize these conversations and encourage proactive care planning. Additionally, digital tools and services can make ACP more accessible, allowing patients to engage in discussions from the comfort of their homes.
Looking Ahead
As the health care landscape continues to evolve, ACP will play an increasingly vital role in shaping patient-centered care. Advances in technology can further enhance the documentation and accessibility of ACP directives, ensuring that patient preferences are easily shared across care teams.
A cultural shift toward viewing ACP as a routine aspect of medical care—rather than as an end-of-life discussion—can help integrate it into standard health care practices. By prioritizing patient preferences and equipping care teams with the necessary tools for effective ACP, the health care system can become more compassionate, proactive and responsive to individual needs. As ACP continues to gain prominence, its role in improving patient outcomes, physician satisfaction, and overall health care efficiency will become even more evident.