One of the reasons that I founded National Healthcare Decisions Day (NHDD) was because of the far-too-common problem of seeing patients who had been in the hospital for several days without having their healthcare wishes documented and without having a healthcare decision-maker named.  Why and how does this happen?  I believe the answer is that there are several gaps in the healthcare system.

One gap is that people are busy and no one slows down long enough to ask the simple question: have you named a decision-maker in the event something happens and you cannot speak for yourself and are there any specific wishes you want to share about your healthcare?  Yet, time shouldn’t be an issue.  There are countless occasions during a patient’s stay during which someone could ask the question, even if it is while tending to another task. 

Another gap is that there is not a good tracking mechanism in many facilities.  All patients are asked about advance directives upon admission, but then the issue gets dropped when the patient is actually in place and receiving care.  In many cases, no one thinks about the issue until the patient becomes unable to make his/her own decisions.  There is an easy fix to this: a checklist or some routine applicable to all patients.  For example, make advance directives a part of a patient’s history and physical.  Another option is to ask that the electronic health record system be programmed to flag the issue until there is an answer as to who a patient’s authorized decision-maker is.  

The final gap is that everyone seems to think that asking/taking about advance directives is someone else’s job.  Doctors think nurses are supposed to do it, and vice versa.  Patients expect their doctors to ask the question if it is important, and doctors feel that their patients will raise the issue if they’ve got strong opinions about their care.  Similarly, family members and patients each are expecting the other to raise the topic.  The result is that the ball gets dropped.  The easiest way to close this gap: have everyone raise the issue.  If the topic has already been adequately covered, it is easy enough to say so, but too often it isn’t raised at all.  NHDD, on April 16, is a great way to close the gap.  If everyone would mark their calendars and raise the topic of advance care planning with their loved ones, we’ll close the gap considerably.

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