Advance Care Planning and Goals of Care Communication in Older Adults with Cardiovascular Disease and Multi-Morbidity

People living with mechanical circulatory support (MCS) are at risk for catastrophic complications that require advance care planning (ACP) as part of the preimplantation work up. Palliative care consultants are a mandatory and essential component of the MCS team tasked to enhance conversations. However, in reality, there is often a serious deficiency of ACP communication after the initial implant counseling. A better understanding of opportunities and challenges in ACP can mobilize intensive care unit and step-down nurses to bridge this gap in crucial communication.

To identify and describe MCS individuals’ perceptions of opportunities and challenges for ongoing ACP communication.

A constructivist grounded theory study was conducted with 24 MCS individuals from 2 medical centers in Southern California. Semi-structured interviews were audio recorded, transcribed, and reviewed for accuracy. The data were systematically analyzed through 3 rounds of coding.

MCS clinicians, supportive others, and peers with MCS were identified as stakeholders in ongoing communication. Four categories of opportunities and challenges for ongoing ACP were synthesized from the narratives: identifying context and timing, sharing information, understanding of ACP, and assessing satisfaction. All participants reported a preference for MCS clinicians, including nurses, to initiate ACP conversations.

Understanding opportunities and challenges is key to facilitating ongoing ACP discussions among MCS patients. MCS-trained nurses are positioned to address the dearth of ongoing ACP by facilitating these sensitive discussions. The personal accounts of this sample serve to guide future research and structure training to prepare MCS clinicians for primary palliative care.

Assess correlates of advance care planning (ACP) among midlife and older adults in the United States, with attention to informal planning (e.g., conversations) and formal planning (e.g., legal documentation such as a living will).

Data were collected from a nationally-representative U.S. sample of adults ages 55–74.

Informal ACP was positively associated with greater confidence, history of life-threatening illness, designation as health care decision maker for someone else, knowing at least one negative end-of-life (EOL) story in one’s personal network, a desire to ease surrogates’ decision making, and having a health care provider who had broached ACP. Formal ACP was positively associated with greater confidence, designation as a health care decision maker, having a provider who had broached ACP, and primarily receiving medical care from a doctor’s office, and marginally negatively associated with health worry.

There are relevant correlates of advance care planning at the individual, interpersonal, and health care levels, with implications for increasing uptake of ACP.

A desire to mitigate proxies’ decision-making burden was a significant motivator for ACP conversations. Awareness of negative EOL experiences may also motivate these conversations. Health care providers have a powerful role in formal and informal ACP uptake.

Heart disease is the most significant contributor to morbidity and mortality in older adults. Care decisions are complex because patients may have multiple comorbidities, frailty, cognitive impairment, and polypharmacy. Additionally, older adults often have vague symptomology, nondiagnostic electrocardiograms, and a reported delay of treatment. Although multiple clinical guidelines are available, the applicability of guidelines to the older population needs to be evaluated based on a holistic, individualized basis. Emphasis should be on patient-centered outcomes and priorities, incorporating risk-benefit assessment, quality of life, functional assessment, and frailty assessment when making treatment decisions.