On the limitations of Advance Care Planning

ACP is intended to help individuals understand and express their values, goals, and preferences regarding future medical care, choose and prepare a trusted surrogate decision-maker, and document their wishes so they can be followed when they lose decision-making capacity. 

Advance Care Planning (ACP) has been widely advocated for the past 30 years as a way of improving end-of-life care by aligning medical decisions with patients' values and preferences. However, today we know that scientific data does not support the notion that ACP improves end-of-life care or ensures goal-congruent treatment:

• A 2018 review of 80 systematic reviews (covering 1,600 studies) found no evidence that ACP improves medical decision-making, increases goal-concordant care, or enhances patient and family satisfaction.

• A 2020 review of 62 high-quality studies also found no link between ACP and better patient care outcomes.

• Five large randomized clinical trials involving cancer patients, nursing home residents, older adults, seriously ill patients, and heart failure patients found no significant differences in healthcare utilization, patient quality of life, or alignment of care with patients’ preferences between ACP participants and those receiving usual care.

Some argue that ACP remains an essential part of good end-of-life care. However, more and more experts argue against over-reliance on ACP, as it diverts resources from more effective interventions. Problems with ACP include:

• Changing patient values and preferences influenced by health status, age, culture, and financial factors.

• Surrogates struggling to interpret past discussions and balance them with present circumstances.

• Poor documentation that is either too vague (e.g. no heroic measures), too rigid or hard to access.

• Healthcare system constraints, such as institutional practices and financial incentives, that shape decision-making beyond patient preferences.

Alternative Approaches

To improve end-of-life care, we suggest:

1. Encourage the appointment of a consenting surrogate decision-maker with whom one has shared their values and preferences as part of a continuous discussion

2. Implement appropriate educational initiatives to strengthen end-of-life literacy and promote free and informed decisions

3. In legislations where legal professionals are called upon to participate in advance care planning, encourage collaboration between legal and health professionals.

References:

1. Fagerlin A, Schneider CE. Enough. The failure of the living will. Hastings Cent Rep. 2004 Mar-Apr;34(2):30-42. PMID: 15156835.

2. Morrison RS, Meier DE, Arnold RM. What's Wrong With Advance Care Planning? JAMA. 2021 Oct 26;326(16):1575-1576. doi: 10.1001/jama.2021.16430. PMID: 34623373; PMCID: PMC9373875.

3. Heyland DK. Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP). Healthcare (Basel). 2020 Jul 18;8(3):218. doi: 10.3390/healthcare8030218. PMID: 32708449; PMCID: PMC7551637.