Family Medicine · Year 3 · from Family Medicine

Case 3: Advance Care Planning

Patient Demographics

• Age: 78 years old
• Sex: Female
• Occupation: Retired nurse
• Living Situation: Lives with husband; daughter lives nearby

Chief Complaint

"I've been thinking a lot about what I want if I get really sick. Can we talk about that?"

History of Present Illness

Mrs. Barbara Williams is a 78-year-old woman with metastatic breast cancer presenting for a routine follow-up. She was diagnosed with breast cancer 4 years ago, underwent mastectomy and chemotherapy, but developed bone and liver metastases 18 months ago. She has been on palliative chemotherapy but her oncologist recently informed her that the disease is progressing. Her functional status has declined over the past 3 months - she now uses a walker, tires easily, and has lost 10 pounds. She has been thinking about "what comes next" and wants to discuss her wishes.

Past Medical History

• Metastatic breast cancer (bones, liver)
• Hypertension
• Type 2 diabetes mellitus
• Former smoker (quit 20 years ago)

Current Medications

• Multiple (managed by oncology)
• Pain controlled on scheduled acetaminophen and as-needed low-dose oxycodone

Functional Assessment

• ADLs: Independent with setup assistance
• IADLs: Needs help with shopping, housework, meal preparation
• ECOG Performance Status: 2 (ambulatory, capable of self-care, unable to work, up and about >50% of waking hours)

Family Situation

• Married to supportive husband for 55 years
• Daughter is local and involved
• Son lives out of state
• Has not discussed end-of-life wishes with family yet

Physical Examination

• Vital Signs: BP 128/72 mmHg, HR 78, Weight 128 lbs (down from 138 lbs 3 months ago)
• General: Thin, appears fatigued but comfortable, no acute distress
• Abdomen: Palpable liver edge 4 cm below costal margin

Clinical Image

Image: Overview of advance directive documents including the healthcare proxy/durable power of attorney for healthcare and living will, showing how these documents work together to ensure patient wishes are honored.

Image Source: Wikimedia Commons Attribution: National Institute on Aging, Public Domain URL: https://commons.wikimedia.org/wiki/File:Advance_care_planning.png

Advance Care Planning Conversation

Opening the Discussion: "Thank you for bringing this up. These are important conversations. I want to understand what matters most to you so we can make sure your care aligns with your values. Can you tell me what you understand about your illness right now?"

Patient's Understanding: "I know my cancer is getting worse and the chemo isn't working like it used to. I'm a nurse - I've seen people at the end of life. I don't want to be on machines if there's no hope. But I also want to be comfortable and spend time with my family."

Values Clarification:

What matters most to you in your life right now? "Being with my husband and family. Being comfortable. Not being a burden."

What abilities are so important that you can't imagine living without them? "Being able to recognize my family. Being able to communicate. If I'm just lying there not knowing anyone, that's not living to me."

What are you afraid of? "Pain. Being hooked up to machines. My husband having to make impossible decisions alone."

Goals of Care Discussion:

Given your values, we have several options to discuss:

1. Continue current approach - oncology follow-up, symptom management
2. Transition to comfort-focused care (hospice) - when the time is right
3. Document specific preferences for emergency situations

Specific Preferences Discussed:

Healthcare Proxy Discussion:

• Patient wants to designate her husband as primary healthcare agent
• Daughter as alternate if husband unable
• Will discuss with both to ensure they understand her wishes

Documentation and Action Items

Completed Today:

1. Documented advance care planning discussion in detail
2. Provided state-specific advance directive forms
3. Discussed POLST (Physician Orders for Life-Sustaining Treatment) - will complete when patient ready

Patient To-Do:

1. Complete advance directive paperwork
2. Discuss wishes with husband and daughter
3. Bring completed forms to next visit for medical record

Follow-Up Plan:

• Return in 2 weeks for forms review and POLST completion
• Palliative care referral for concurrent symptom management
• Hospice discussion when patient feels ready
• Continue regular oncology follow-up

Teaching Points

1. Advance care planning should begin while patients have capacity - don't wait until a crisis

1. Values clarification precedes specific decisions - understanding what gives life meaning guides treatment choices

1. Healthcare proxy is often more important than a living will - a trusted decision-maker can respond to unforeseen circumstances

1. POLST translates goals into actionable medical orders - appropriate for patients with serious illness or advanced frailty

1. These conversations should be revisited - preferences may change as illness progresses

1. Document thoroughly - the conversation is as important as the paperwork

1. Involve the designated proxy - they need to understand the patient's values to make decisions if capacity is lost

Key Teaching Points Summary

Comprehensive Geriatric Assessment

• Assess all domains: medical, functional (ADLs/IADLs), cognitive, psychological, social, environmental
• Functional status is the strongest predictor of outcomes in older adults
• Timed Up and Go >14 seconds indicates high fall risk

Polypharmacy and Deprescribing

• Beers Criteria identifies potentially inappropriate medications
• Anticholinergics (diphenhydramine, oxybutynin) are high-risk for cognition and falls
• Deprescribing is an active therapeutic intervention, not "giving up"
• Start low, go slow - also applies to stopping medications (taper when appropriate)

Delirium Recognition

• CAM: Acute onset + inattention + (disorganized thinking OR altered consciousness)
• Hypoactive delirium is more common but often missed
• UTI is the most common precipitant in older adults
• Treat the underlying cause; avoid antipsychotics unless severe agitation

Advance Care Planning

• Begin while patient has capacity
• Values clarification guides specific decisions
• Healthcare proxy designation is critical
• Document thoroughly and revisit periodically

All cases for this lecture as Markdown