Gaining a Better Understanding of Advance Directives and Medical Necessity

Health systems should consider not only the ailment inflicting the patient, but the person being impacted by this care and what this means to them.

Listening to one of our hospital partners describe rounds with complex cases, I heard of the following scenario: the patient was an 80-year-old male with advanced dementia, living in a nursing home with his wife, on day 20 in the hospital following an infection that impacted his previous shoulder replacement hardware, requiring removal and an antibiotic spacer. The patient also had a prior hip surgery and now had his infection impact this implant as well, requiring a replacement. The patient was found to have needed at least six weeks of IV antibiotics and another surgery for his shoulder, following completion of the antibiotics. Patient was still primarily bed-bound; his arm was in an immobilizer. The patient will need post-acute placement for IV antibiotics; however, due to his cognitive level, they were having difficulty placing him, and he became too acute to return to his nursing home. The patient was stable for discharge; however, they were unable to find an accepting facility, given his new level-of-care needs, thus rendering him unable to return to his home or his wife.

Understandably, there are a lot more details to this case that we will not cover in this article. However, the questions I asked the team at rounds was, “what was the patient’s goals of care?” and more specifically, “what were his advance directives?” Did this gentleman and/or his wife want to go down the road of significant treatment during this hospitalization? What does his future look like, knowing he will return to the hospital for more high-risk surgeries? The group replied, “we don’t know!” – and guess what, the chart did not know either. Granted, in the pressure involved with securing beds, the intention of the meeting was about “why has this patient not left yet?” However, as case managers, we are stewards to not only the progression of care, but also the utilization management of the organization. We must follow a standard of care to advocate on behalf of our patients.

Now, say the patient and/or wife said yes, we want to do everything. Then this example may look very different as it relates to the questions. Does the wife understand what “do everything for her husband” means? However, it was clear that this was a process error, with failure to stop and ask the necessary questions. When we consider value in care delivery, we must examine outcomes, which Dr. Hirsch confirms are incredibly hard to define. I will ask, “what is the likely outcome of this patient, and the intended impact to his already declining quality of life?”

Enacted in the 1990s, the Patient Self-Determination Act requires that hospitals and post-acute providers ask patients if they have an advance directive or a medical power of attorney, and/or check on their wishes prior to medical treatment. The intent of the law is to provide an opportunity for adults to express their desires about medical treatment in advance, and to educate the entire population on advance directives.Additionally, outpatient providers are incentivized financially through CPT® code 99497 to have advance directive conversations with their patients. However, a 2020 review of more than 60 high-quality recent studies on advance care planning found no impact on whether patients received the care they wanted, or how they rated the quality of their lives afterward.

In the quest for medical necessity and the pressure for achieving the appropriate level of care, I encourage our health systems to consider not only the ailment inflicting the patient, but the person being impacted by this care and what this means to them. Quoted from Dr. Daniela Lamas, in her New York Times essay “A Better Way to Face Death,” maybe we should be asking how our patients want to live, instead of how they want to die.

So today I ask, do you think the current process of obtaining advance directive information in your health system is having an impact on your hospital’s outcomes?

Programming Note: Listen to Tiffany Ferguson’s live reports on the social determinants of health (SDoH) every Monday on Monitor Mondays, 10 Eastern.