DS-ACP interview Specifically, the DS-ACP structured interview with the patient and proxy includes
● Assessment of the patient’s and proxy’s understanding of the patient’s disease, symptoms, and possible complications
● Discussion of the patient’s values, worries, and fears regarding illness, quality of life, coping strategies, and past and present experiences with the end of life
● Review of previously expressed patient preferences from existing documents and discussions with family
● Review of the purpose of ACP and the role of the proxy
● Discussion of complications and scenarios related to the patient’s disease trajectory (this stage uses a Statement of Treatment Preference form to guide the discussion and assist the patient in clarifying goals for treatment)
● Review of the patient’s decisions, including the proxy’s understanding of and ability to honor the choices the patient makes
● Follow-up activities, including further discussions with the patient’s physician, arranging needed services, additional ACP discussions, and completion of appropriate written advance care plans such as the Health Care Agent, Health Care Directive, Statement of Treatment Preferences, and Provider Orders for Life Sustaining Treatment. Copies are filed in the medical record and given to the patient and the proxy, and the facilitator follows up with the provider about the decisions they have made.19
Certified facilitators A key component of the program is the use of certified facilitators during the DS-ACP discussion. The Respecting Choices DS-ACP Facilitator Certification Program identifies and reinforces a set of skills to help engage patients with chronic, progressive, and life-limiting illness, and their families, to make timely and informed health care decisions specific to the complications they are likely to face in the future. The program also aims to open the channels of communication between the patient, family, and health care providers. Facilitators complete a rigorous, competency-based communication skills training program that includes an online course to be completed before the classroom experience. In the intensive 2-day classroom experience, participants are exposed to an identified set of interview and communication competencies through video demonstration, individual and group role-play practice activities, and group discussion. A competency checklist of expected facilitator behaviors is used to clearly define the expectations of performance and to evaluate role-play activities. Participants are required to submit a video role-play demonstration 2 to 3 weeks after the classroom course. Individual performance is evaluated through the use of the competency checklists, and feedback is provided on areas needing improvement. Certification ensures the DS-ACP intervention is delivered in an effective, consistent, and reliable manner.
OUTCOMES OF THE DS-ACP MODEL
The Respecting Choices DS-ACP was tested for immediate outcomes in four randomized trials of patient-proxy pairs. Three small studies with patient-proxy pairs conducted among patients with congestive heart failure, end-stage renal disease, cardiac surgery, and HIV (adolescents only) all found that the DS-ACP intervention was associated with increased congruence in decision-making between patient and proxy on the statement of treatment preferences and demonstrated reduced decisional conflict among patients in the DS-ACP group as compared to the standard treatment patients. Two of the studies found a positive association with the quality of provider communication.19-21 A larger trial involving 313 patient-proxy pairs with congestive heart failure or end-stage renal disease found a significantly higher degree of understanding of patient goals among intervention surrogates.22 A separate trial in Australia examined facilitated ACP, which includes the same basic elements as DS-ACP, in elderly patients and their proxies. Among patients who died, those who had completed the ACP process were much more likely to have their wishes known and adhered to as compared to the usual care group. Family members of ACP participants also had less stress, anxiety, and depression compared to those in the usual care group.23
POTENTIAL BENEFIT OF DS-ACP IN ONCOLOGY PATIENTS
A review project suggests that the pain and delirium often experienced by cancer patients toward the end of life pro-vide a strong rationale for integrating ACP into oncology care. The project also notes that cancer patients often receive aggressive treatment near the end of life, precisely a time when they might benefit from or prefer more comfort-oriented care.24 Most research on ACP indicates the majority of patients will choose to forgo aggressive treatment near the end of life, opting instead for palliative care.24 In interviews conducted during one study with 342 patients, some with advanced cancer, more patients chose to forgo the more invasive long-term treatments such as mechanical ventilation and feeding tubes.25 Another study found that older patients with metastatic cancer would choose artificial tube feeding less frequently than physicians use it in their practice.26
Another observational prospective cohort study of terminally ill cancer patients found that having end-of-life discussions was associated with lower rates of ventilation, resuscitation, and ICU admission and with earlier hospice enrollment. The study also found an increased quality of life for both patients and their caregivers when less aggressive treatments were provided. Caregivers of patients who underwent aggressive treatment were more likely to experience mental health problems such as depression and feelings of regret after the patient’s death.18 Given these findings, being aware of and honoring a patient’s choices would likely result in fewer hospitalizations, increased hospice use, and better quality of life for oncology patients. While research has yet to be conducted on the use of DS-ACP in cancer patients, the process is currently practiced among cancer patients in two health care systems. The initial experience, as illustrated in the Case Scenarios that accompany this article, suggests that the process was useful for cancer patients and their proxies.