The past year has demonstrated that advance care planning conversations are more important than ever. As the infection rate and the death toll of COVID-19 continue to rise, it is important that these end-of-life care conversations are facilitated by skilled clinicians, and that these care preferences are documented and available in all healthcare settings. As a result, nurses have increasingly been recognized for their ability to facilitate these discussions with patients and their families.
The Role of Nurses in Advance Care Planning
A few years back, the American Nursing Association (ANA) and the Hospice and Palliative Nurses Association (HPNA) came together and wrote the 2017 Call for Action: Nurses Lead and Transform Palliative Care, which was intended to urge nurses in various roles and care settings to lead and transform palliative care and outlined how all nurses should have the knowledge, skills and abilities to provide primary palliative nursing. The conclusion was that “seriously ill and injured patients, families and communities should receive quality palliative care in all care settings. This is achieved by the delivery of primary palliative nursing by every nurse, regardless of setting.”
In addition to the Call for Action, each organization also issued position statements on advance care planning. The HPNA position highlights that advance care planning is at the principle of true of patient-centered care and nurses must take a leading role in the process by implementing the education of patients, their families, and other healthcare clinicians into their everyday practice. The ANA position states that it is a nurse’s obligation to provide comprehensive and compassionate care at the end-of-life, and they, along with other healthcare providers, should engage in shared decision-making to establish goals of care for the patient.
The Benefits of Having Nurses Lead Advance Care Planning Conversations
Leveraging nurses to engage and guide patients through this process may seem like the obvious choice for several reasons:
- Relationship – Nurses are often in the frontline position when it comes to patient care and interacting with individuals and their families. As such, many patients may feel a closer connection to the nursing staff than they do with their physician. This rapport can make it easier to conduct these sensitive conversations around end-of-life care goals and preferences.
- Time – Physicians are often overbooked and only able to spend a set amount of time with each patient. While nurses are also busy, they are often in a better position to dedicate the time needed to have the initial conversation and any follow-up discussions – making them a logical choice to facilitate.
- Training – Very few medical schools in the U.S. focus on training physicians to have advance care planning conversations. Therefore, it makes sense to focus on teaching other healthcare providers to engage and lead these conversations with patients and their families.
Nurse Navigation Increases Advance Care Planning
In a recent study published in JAMA, researchers looked at the impact of leveraging nurse navigators in a population of adults 65+ with multi-morbidities. Half of the participants were guided through advance care planning with a nurse navigator while the other half followed the usual process. The study showed that those individuals in the nurse navigator-led group had a higher rate of advance care planning documentation (42.2% vs. those who did not 3.7%). They also saw that billing codes were more frequently used for those working with a nurse navigator (25.3% vs. 1.3%). This group was also more likely to designate a surrogate decision-maker (64% vs. 35%) and ultimately had a higher rate of form completion (24.3% vs. 10%).
These findings help support the theory that patients are more likely to discuss and complete documents when they are introduced and guided by a trained clinician. Organizations also have the opportunity to maximize billing potential with guided advance care planning.
The Preparer Role Within Vynca’s Solution
Within Vynca, each user is assigned a role. One of these roles is a Preparer. A Preparer is a clinician or facilitator who engages in advance care planning conversations with the patient and can start the document completion process but cannot sign certain medical orders, such as a POLST form. Preparers usually include roles such as nurses, social workers, care managers, etc.
Documents Initiated by a Preparer During the Early Days of COVID
Last year, we looked back on the impact of advance care planning during the first few months of COVID-19. One area we focused on was the role of the Preparer. From February 2020-May 2020, we saw the number of documents initiated by a Preparer increase.
| Month | February | March | April | May |
| Initiated by Preparers | 14% | 11% | 19% | 27% |
Advance Care Planning is Billable
It is also important to remember that advance care planning is billable, with dedicated CPT codes. When considering whether nurses can provide reimbursable advance care planning services, it is important to consult your state’s specific scope of practice regulations. Some states afford non-physician providers greater freedom to help patients complete advance care planning documents while other states adhere to a hierarchical standard of medical supervision.