Advance Care Planning: What We Can and Cannot Do

Several recent articles about advance care planning (ACP) have demonstrated that the rates of completing advance directives have remained unchanged over the past few decades despite COVID-19, the increased prevalence of dementing diseases, and our access to resources which could inform our decisions as we age. 

In most issues of the Journal of the American Geriatrics Society (JAGS) or the Journal of the Society for Post-Acute and Long-Term Medicine (JAMDA), at least one article highlights the issues for the need to address end-of-life care in individuals with dementia. 

I thought that we were making progress in developing a more uniform approach to discussing ACP; however, it was not until I began taking fourth year medical students to a postacute facility for a week-long exposure to how care is actually delivered in these facilities that I appreciated the disconnect between what we can and cannot do.

While touring the students around the facility, I include the crash cart, which is located in each nursing unit. As I remove the cover, the students universally look on with amazement as the cart consists of oxygen and a suction machine. They asked, “Where are the medications? The intubation set up? The other devices and supplies to run a code?”

“Those are in the emergency medical services unit or the emergency room—not here as we do not have physicians who can intubate or intravenously push medications in a nursing home,” I have replied. The sight of the crash cart and the realization regarding the limited effectiveness of CPR in postacute care comes as a complete surprise to every student.

My students who plan to enter residencies in emergency medicine often remark at the end of the rotation that the week in postacute care will shape their care, as well as attitudes, about nursing homes and nursing home residents. 

Rather than blaming the postacute facility “for the terrible condition this patient is in,” the students understand how hard the nursing staff work, how many more residents they have as compared to hospital nurses, how complex both medically and psychiatrically the residents are and how much the system depends on the nurses to be the eyes and ears of the physician. 

I only wish I had more than 2 students at a time who could see what we see. I cannot help but think this would help physicians have a better understanding of the realities of postacute care.