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Helping You Help Our Patients

We encourage our valued providers and healthcare partners to take advantage of these resources to help you guide and support advance care planning discussions with your teams and patients.
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Please Note

The external websites linked to from this webpage contain the information and viewpoints approved by those organizations. While we do believe these websites contain valuable resources that may be useful to you, these links do not represent an official endorsement of any other organizations' materials by Inova Health System.

Ascertaining and understanding a patient’s wishes is an important component of high-quality care. Clinicians should always ensure patients receive care that aligns with their values and goals. With the new reality of the COVID-19 pandemic, the importance of providing goal-concordant care has become heightened. Now more than ever, it is crucial for people to have these important personal conversations with their healthcare providers and families and to make decisions prior to the possible development of serious acute illness.

As medical providers, the types of conversation you may have with your patient about health care goals and wishes will vary based on your patients’ current condition and location of care. 

The palliative care and geriatric teams, along with medicine leadership at Inova have compiled this list of resources to help you guide your patients in expressing their healthcare wishes, verbally and in writing.

What is Advance Care Planning?

Advance care planning is the process of planning for future medical care, particularly for the event when the patient is unable to make his or her own decisions. It may also help relieve family members and physicians of their concerns in making difficult decisions during challenging moments. It should be a routine part of standard medical care. It may include advance directive documents such as a living will, power of attorney for healthcare decisions or healthcare agent.

Why is it important?

An advance directive allows a person to document or verbally state to healthcare professionals and family in advance what their wishes are before that individual is unable to make decisions at the end of life.

It is okay to feel uncomfortable to speak with a patient about final wishes. Just remember that if there is no written document or discussion ahead of time then no one will know how the patient would like to be treated. Each patient conversation flows differently and being aware of available resources in different stages of the discussion will empower you moving forward in helping patients and their family members.

What are Goals of Care?

Goals of Care describe what a seriously ill patient wants to achieve during an episode of care, within the context of their clinical situation. Goals of care are the clinical and personal goals for a patient's episode of care that are determined through a shared decision-making process.

What is the difference between Advance Care Planning and Goals of Care?

Advance Care Planning conversations are intended to collect broad and detailed information from any adult patient, healthy or sick, for future reference. Advance Care Planning is an ongoing conversation driven mostly by the Primary Care practice. Goals of Care conversations seek the immediate collection of patient wishes and desires that are specific to a diagnosis or condition. Goals of Care conversations are initiated by Providers.

Advance Care Planning – Primary and Specialty Care

Advance Care Planning – Community and Post-Acute Partners (e.g., Assisted Living Facility, Home Health, Hospice, Skilled-Nursing Facility)

What documents are part of ACP?

ACP includes several documents:

  • An advance directive and living will – a written document stating a patient’s wishes about healthcare decisions in the event the patient becomes unable to make healthcare decisions in the future.
  • A durable do not resuscitate (DDNR), physician’s orders of scope of treatment (POST) or equivalent form – a signed medical order for specific healthcare to be provided to, or withheld from, a patient in the event of a medical emergency, such as cardiac arrest.
  • A guardianship or custody document – a court document granting decision-making authority to a guardian or custodian for a patient deemed legally incompetent.
  • Learn More About Advance Care Planning Document Types

Who can have ACP conversations?

An ACP conversation can be started by any member of your care team or support network (e.g., family members, neighbors, friends). Several disciplines can bill for these conversations.

  • Surrogate – an adult authorized by Virginia statute to make medical decisions for a decisonally incapacitated patient when there is no applicable advance directive or appointed agent.
  • A power of attorney – an adult legally appointed by the individual in an advance directive to make healthcare decisions in the event of the individual's decisional incapacity. The PoA is also known as medical power of attorney, agent, or healthcare agent.

How do I access my patients' ACP documents on file at Inova?

EpicCare Link is a free, enhanced read-only application offering community providers secure, remote access to view their patients' Inova medical records. Learn more

How do I share my patients' documents with Inova?

It is important for Inova to have a copy of your patients’ most recent ACP documents as soon as they are available. Fax them to us at 571-472-6505 or email to acpsubmissions@inova.org.

What training and educational resources are available?

Additional Educational Resources:

Goals of Care

Preparing for the Conversation:

  • The Surprise Question is a simple evidence-based screening tool for providers to help identify patients who can benefit from a Goals of Care conversations. This tool involves a clinician reflecting on the question, “Would I be surprised if this patient died in the next 12 months?
  • How to use the Surprise Question
    • Ambulatory. PCPs or Specialists seeing seriously Ill and/or comorbid patients should regularly ask themselves the surprise question. For any patient for whom the answer is "No," the provider should prepare to discuss the patient’s goals of care. The conversation should be initiated by the provider most familiar with the patient and/or most knowledgeable of their diagnoses and treatment.
    • Inpatient. Attending Providers will look for multiple triggers (e.g., Palliative Care Screening tool, patient’s condition, frequent readmissions, ICU LOS, full code applicability, lack of independence/quality time) to use the surprise question tool at Admission, Trio Roundings and MDRs. If the answer to the surprise question is no, the Care Team will discuss the plan to approach the conversation with the patient and family.
  • Resources: Using the Surprise Question to Trigger Patients, The Surprise Question as a Prognostic Tool
  • Training: Inova's HealthStream: POST Training, Virginia Post Course
  • Support: GoC Provider Resource Network (coming soon)

Having the Conversation:

Documenting the Conversation:

Things to Consider:

  1. Use every opportunity to have GoC conversation to timely collect the most essential information
  2. Document and share across the entire Care Team (inpatient and ambulatory) the GoC information collected in any visit
  3. Get to know your patients at a personal level to strengthen the relationship and trust and frame any conversations in a way that strengthens that trust and pursing the best quality of life for the patient
  4. Provide patients with the most appropriate information for them to make their best decision
  5. Recognize patient's cultural context before initiating conversations
  6. When using the Serious Illness Conversation Guide, frame questions to avoid misinterpretation
  7. Think about how engaged and informed family members are, and their decision-making authority and ask patients how they would like their family members to be included.
  8. Initiate the conversation as early as the patient is ready, including the concept of reversibility (i.e., prognosis can reverse), so it less of a surprise later – Ambulatory Only
  9. Collect input from Nurses and Medical Assistants on patient that will benefit from GoC conversations – Ambulatory Only
  10. Make time to have the conversation on Annual Wellness Visits (AWV) for the appropriate geriatric population (e.g., 80+ yrs). – Ambulatory Only
  11. GoC can be billed separately if done outside of a regular AWV. – Ambulatory Only
  12. The Palliative Care Screening Tool is a quick tool to identify patients who can benefit from GoC conversation, and it is not intended to assess every patient every time – Inpatient Only

Ambulatory Roles and Responsibilities:

  • The provider, PCP or Specialist, who has the broader understanding of the diagnosis and treatment, and/or a high level of trust from the patient would be responsible for initiating Goals of Care conversation
  • Clinical Teams through existing Daily Huddles will help providers identity patients for Goals of Care conversations
  • The provider who initiated the conversation is responsible for documenting it in Epic and proactively notifying the Care Team about it

Inpatient Roles and Responsibilities:

  • It is recommended that Attending initiates the conversations
  • Inpatient Providers must ensure GoC information is documented on sign-out materials if conversation is still in progress
  • Care Team will coordinate next steps once a patient was identified for having GoC conversations
  • Nursing supports GoC by helping identify patients that can benefit from the conversations, and also by preparing patients for the conversation

Additional References: