Learn how healthcare professionals can ensure that their patients’ voices are heard by embracing advance care planning (ACP), defined as honest conversations about how patients want to be cared for at the end of life if they are unable to communicate or make decisions. This webinar explores advance directives, the legal documents that spell out patients’ wishes for family members, caregivers and healthcare teams.

1. Advance Directives & Advance Care
Planning for Health Care Providers
Making the Patient’s
Voice be Heard
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2. CE Provider Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS
Healthcare Corporation of Florida, Inc/CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home
Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS
Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider
Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois
Respiratory Care Practitioner.
VITAS Healthcare programs in California/Connecticut/Delaware/Illinois/Northern Virginia/Ohio/Pennsylvania/Washington DC/Wisconsin are
provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social work
continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE)
program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/15 - 06/06/18). Social Workers
participating in these courses will receive 1-2 clinical or social work ethics continuing education clock hour(s). {Counselors/MFT/IMFT are not
eligible in Ohio}
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered
Nursing, Provider Number 10517, expiring 01/31/2019.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA:
No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois
06-2017
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3. Goal
• To familiarize health care providers with advance directives and
advance care planning, as well as with Medicare’s new perspective
on advance care planning services.
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4. Objectives
• To review the origin and meaning of advance directives
• To define the types of advance directives and their function
• To provide guidance and resources on advance directives
• To review HEDIS measures on care for older adults
• To define advance care planning (ACP)
• To review Medicare’ s reimbursement
for provided ACP services
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5. A little background…
• End-of-life issues: patient autonomy, quality of life at the end of life,
and withdrawal of life-sustaining treatments
• In 1990, Congress enacted the Patient Self-Determination Act:
− Accept a patient’s right to either refuse or accept medical
treatment,
− Safeguard the patient’s autonomy and preserve self-determination
− Protect patients against maltreatment
− Foster communication between patients and their physicians
− Protect physicians from litigation in end-of-life decision making
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6. Karen Ann Quinlan
• On April 14, 1975 the 21-year-old stopped breathing and
lapsed into a coma.
• After five months, doctors diagnosed Quinlan as being in a
persistent vegetative state.
• Her parents requested that Quinlan be disconnected from
the machines that were sustaining her.
• Her doctors refused, so they took the case to court - one of
the first "right to die" case in U.S. legal history.
• Weaned from the respirator, she survived for nearly 10
more years, dying of pulmonary failure on June 11, 1985.
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7. Nancy Cruzan
• On Jan. 11, 1983, then 25, Cruzan had a wreck on a country
road in southwest Missouri and is thrown from the car.
• On Oct. 23, 1987: Cruzan’s parents requested that they be
allowed to have Cruzan’s feeding tube removed.
• On July 27, 1988, the Cruzans were authorized to request
the withholding of food and water from their daughter.
• On Nov. 16, 1988, the state Supreme Court overturned the
decision. The family appealed to the U.S. Supreme Court.
• Dec. 26, 1990 County court ruling allowed Cruzan’s parents
to remove the feeding tube. Cruzan died 11 days later.
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8. Terri Schiavo
• On February 25, 1990, 26-year-old Terri collapsed at home
in the early morning hours.
• In June 1990, Michael Schiavo, Terri’s husband, was
appointed her plenary guardian by the courts.
• In May of 1998, Michael Schiavo filed a Petition to
Withdraw Life Support.
• On March 18, 2005, Terri’s feeding tube was removed for
the third and final time.
• On March 31, 2005 after almost 14 days without nutrition
or hydration, Terri died from severe dehydration.
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9. Bobbi Kristina Brown
• On Jan. 31, 2015, the 21-year-old was found unresponsive
in her bathtub and was rushed to the hospital, where she
was placed in a medically-induced coma.
• On March 21, 2015, she was moved to a rehabilitation
facility in Atlanta. She remained in a coma.
• On June 24, 2015, Bobbi Kristina was moved into a hospice
care facility.
• On July 26, 2015, she died at the age of 22 after being in a
coma for nearly seven months.
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10. Advance Directives
• Advance directives are legal documents
that allow the patients to formally state
their choices regarding what actions
should be taken for their health in case
they are no longer able to make
decisions for themselves because of
illness or incapacity

11. • Advance directives were developed to provide a practical process for
ensuring patient autonomy at the end of life, giving a voice to the
patient’s preferences for medical care within the spectrum of
reasonable clinical options
Advance Directives (Cont.)

12. • Advance directives have become increasingly specific, often
containing patient preferences for a variety of medical treatments in
hypothetical medical scenarios
• Advance directives are not an end in themselves - They are most
effective when incorporated into a comprehensive advance care
planning process, which helps identify what course serves the
patient best and then outlines specific steps to make that course
more likely
Advance Directives (Cont.)
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13. Types of Advance Directives
• Advance directives vary depending on state law and individual
preferences within the states’ legal requirements
• The 2 most common types of advance directives are:
− The Living Will
− The Durable Power of Attorney for Health Care
• Advance directives can also allow patients to specify when they do not
want to be resuscitated or if they want to make organ or tissue
donations
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14. The Living Will
• A Living Will is a document designed to control certain future health
care decisions only when a person becomes unable to make
decisions and choices on their own
• The person must also have a terminal illness or permanent
unconsciousness
• The living will describes the type of medical treatment the person
would want or would not want in these situations.

15. The Living Will (Cont.)
• The living will can describe under what conditions an attempt to
prolong life should be started or stopped, including treatments such
as:
− Dialysis
− Tube feedings
− Artificial life support
• It can also include:
− “Do not resuscitate” orders
− Whether patients want to donate their organs or other body tissues
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16. Important Factors to Consider
• Choosing not to have aggressive medical treatment is different from
refusing all medical care
• The patient may revoke a living will at any time
• There’s no general agreement for recognizing living wills from other
states
• A living will is much more limited than a health care power of attorney

17. Durable Power of Attorney for
Health Care
• A durable power of attorney for health care it’s a legal document in which
patients name a person to be their proxy (agent) to make all their health
care decisions if they become unable to do so
• The patient’s proxy can speak with all caregivers on their behalf & make
decisions based on directions they gave earlier
• If the patient’s wishes in a certain situation are unknown, the proxy will
decide based on what he/she thinks the patient would want
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18. Durable Power of Attorney for
Health Care (Cont.)
• The person named as the patient’s proxy or agent should be someone
the patient trusts to carry out his/her wishes
• The patient should name a back-up person in case the first choice
becomes unable or unwilling to act on his/her behalf
• The law doesn’t allow the agent to be a doctor or a nurse providing
health care to the patient unless he/she is a close relative
• Most state laws require requests for a proxy to be in writing
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19. “Do Not Resuscitate” Orders
• Resuscitation means an attempt by medical staff to re-start the
patient’s heart and breathing, such as CPR
• In some cases they may also use life-sustaining devices such as
breathing machines
• A “Do Not Resuscitate” or DNR order means that if the patient stops
breathing or his/her heart stops, nothing will be done
to try to keep him/her alive

20. Important Factors to Consider
• If the patient is in the hospital, he/she can ask their doctor to add a
DNR order to their medical record
• The patient would only ask for this if he/she didn’t want the hospital
staff to try to revive them if their heart or breathing stopped
• Some hospitals require a new DNR order each time the patient is
admitted, so the patient may have to ask every time they go into the
hospital
Remember that this type of DNR order is only good
while the patient is in the hospital
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21. Please Remember…
• The patient’s advance directives become legally valid
as soon as he/she signs them in front of the required
witnesses
• However, they do not go into effect unless the patient
is unable to make his/her own decisions
• The patient does not need a lawyer as long as he/she
uses approved, state-specific documents

22. How To Get Started?
• Various organizations make advance
directive forms available. One such
document is “Five Wishes” that includes a
living will and a health care surrogate
(proxy) designation
• “Five Wishes” gives the patient the
opportunity to specify details that might
bring the patient comfort
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23. The Five Wishes
• Five Wishes is an advance directive created by the non-profit
organization Aging with Dignity
Wish 1: The Person I Want to Make Care Decisions for Me When I Can't
Wish 2: The Kind of Medical Treatment I Want or Don't Want
Wish 3: How Comfortable I Want to Be
Wish 4: How I Want People to Treat Me
Wish 5: What I Want My Loved Ones to Know
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24. The Five Wishes States
For more information visit: Aging with Dignity
www.AgingWithDignity.org - (888) 594-7437
Five Wishes currently meets the
legal requirements for an advance
directive in 42 states and the
District of Columbia
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25. What to do with Advance Directives
• If the patient has designated a proxy and a backup, make sure he/she
gives them a copy of the document
• Make sure that the patient’s health care provider, attorney, and the
significant persons in his/her life know that he/she has an advance
directive and where it is located – the patient may also want to give
them a copy
• Advise the patient to keep a card or note in their purse or wallet that
states that they have an advance directive and where it is located
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26. Advance Directives in
• Chapter 765 of the Florida Statutes recognizes the right of a
competent adult to make an advance directive
• Although the patient may choose to consult an attorney, the
procedures for preparing advance directives doesn’t require one
• However, an advance directive, whether it is a written document or
an oral statement, needs to be witnessed by two individuals - at least
one of the witnesses cannot be a spouse or a blood relative
An advance directive completed in another state, as
described in that state's law, can be honored in Florida.
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27. Advance Directives and Hospice
• Patients are not required to have advance directives in order to
receive hospice care.
• Hospice staff will discuss the importance of advance directives in
preserving patient choice.
• Hospice offers training on advance directives.

28. HEDIS – Care for Older Adults
• The Healthcare Effectiveness Data and Information Set (HEDIS) is a
tool used by more than 90% of America's health plans to measure
performance on important dimensions of care & service
• For Care for Older Adults, HEDIS measures the percentage of adults
65 years and older who had each of the following during the
measurement year:
− Advance care planning
− Medication review
− Functional status assessment
− Pain screening
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29. Patients and End-of-Life Care
• As people age, consideration should be given to their treatment wishes
in the event that they lose the ability to manage their care
• A large discrepancy exists between the wishes of dying patients and
their actual end-of-life care
• Frequent clinician–patient conversations about end-of-life care values,
goals, and preferences are necessary
• Most patients say they look to their clinicians and other health
care providers to initiate the discussion
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30. Starting the Conversation
• Start off slowly
• Learn a patient's underlying
values and goals
• Ground your discussion in an
experience
• Don't rush
• Don't think that you know all the
answers
• Don't assume patients know the
answers
• Take responsibility
• Don't wait
• Take a closer look at dying
• Don't avoid discussions about
faith
Source: (Kelly, 1999)
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31. Something to
Consider
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32. Advance Care Planning (ACP)
• Advance Care Planning is a discussion about preferences for
resuscitation, life sustaining treatment and end of life care
• Advance care planning must include one of the following:
− The presence of an advance care plan in the medical record
− Documentation of an advance care planning discussion with the
provider and the date when it was discussed. The documentation of
discussion must be noted during the HEDIS measurement year.
− Notation that the member previously executed an advance care
plan.
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33. ACP (Cont.)
• The Institute of Medicine identifies a number of characteristics shared
by the most effective ACP approaches:
− Understanding and treating ACP as a recurring discussion about
someone’s goals, values, and treatment preferences instead of
seeing it as a one-time activity
− Including in ACP conversations those designated as power of
attorney for health care
− Accommodating diverse belief systems that can shape the treatment
decisions people make at the end of life
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34. Physician Reimbursement
for Advanced Care Planning
January 2016
CPT CODES: 99497 & 99498

35. ACP Services
• With the release of Medicare’s Physician Fee Schedule rule, CMS is
indicating that the establishment of payment rates for advance care
planning conversations between physicians and patients can begin as
early as January 1, 2016
• Physicians will receive payment for these important physician-patient
conversations around advance directives & discussions
around patient goals of care

36. 99497 and 99498
• Both 99497 and 99498 apply to advance care planning services
including the explanation and discussion of advance directives such as
standard forms (with completion of such forms, when performed), by the
physician or other qualified health professional
• CPT Code 99497 applies to the first 30 minutes, face-to-face with the
patient, family member(s) and/or surrogate
• CPT Code 99498 is the add on code for each additional 30 minutes
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37. Closing
Thought
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38. Questions?

39. References
• Aging with Dignity. (2015). Five Wishes. Retrieved from www.agingwithdignity.org
• American Cancer Society. (June 2015). Advance Directives.
• Centers for Medicare and Medicaid Services. (July 2015). Revisions to Payment Policies
under the Physician Fee Schedule and Other Revisions to Part B for CY 2016
• Florida Agency for Health Care Administration. (2015). Health Care Advance Directives.
• Gallegos, A. (October 2012). Clearing up Confusion on Advance Directives. American
Medical News.
• Harter, T. (2015). What Kind Of Advance Care Planning Should CMS Pay For?. Health
Affairs Blog
• Kelly. C.K. (March 1999). Tips on Talking to Your Patients About Advance Directives.
American College of Physicians-American Society of Internal Medicine Observer.
• Wilkinson, A. Wenger, N. Shugarman, L. (June 2007). Literature Review on Advanced
Directives. RAND Corporation.
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40. Advance Directives & Advance Care
Planning for Health Care Providers
Making the Patient’s
Voice be Heard