Call to Action: Importance of Advanced Care Planning and Goals of Care Discussions with Patients during the COVID-19 Pandemic

Dear Colleagues,

We are reaching out to you because of the important issue of Advanced Care Planning (ACP) and Goals of Care (GOC) discussions with patients during the current COVID-19 pandemic. This is potentially the most difficult conversation that we can have with patients, but during these dire times, this discussion is important now more than ever. We are requesting that all physicians, particularly the frontline doctors working in primary care (Long-term Care physicians, Family Medicine physicians, and Emergency Medicine physicians) immediately initiate ACP/GOC discussions with their patients who are at high risk for poor outcomes from this virus (elderly, multiple comorbidities, immunocompromised, etc.). We recognize that this is extremely difficult, especially with the use of virtual visits and that in a busy practice, these conversations may consume our visit times.

However, we strongly believe that planning ahead will be key in providing patient centered emergent care when clinical deterioration occurs. As you all may know, Italy, the United States, and much of the globe, are enduring a crisis where ED and hospital physicians are left to make tough decisions regarding mechanical ventilation and life sustaining therapy (on who to ventilate and keep alive) due to the limitation of resources. We may be confronting this in Canada and we will likely not have enough hospital resources to tend to all of our extremely sick COVID-19 patients. We need to be proactive and have these discussions so that our frontline healthcare workers can effectively triage and take care of these patients in accordance with their wishes. Thus, community awareness and comprehension of the disease and its outcomes is essential.

This will be tough on everyone. ACP is extremely challenging even when we are not in a pandemic. However, meaningful and timely discussions can save lives. It also has the potential to:

1. Provide dignity and empower patients to make an informed decision before they get sick.
2. Avoid the difficult conversation in the ED and hospitals where it is not ideal to have the discussion, due to time pressures and that most physicians do not have long term relationships with these patients. (Due to the physical restrictions in the hospitals for families to be with their patients, this will become even more difficult).
3. Alleviate an extremely challenging decision for the family to make when a patient is unable. We sincerely hope that as leaders and respected caregivers in your community, you can put this into action and be proactive in the current critical situation. Together, we can help to make a difference for our patients and for our frontline health workers.

Here are a few suggestions that you can implement in your practice immediately.

1. Primary Care Physicians

During your scheduled televisits and clinic visits, if you identify that an individual is elderly or high risk (immunocompromised or multiple comorbidities), please try bringing up goals of care and advanced care planning discussions with your patients and families. If possible, clarifying code status will be vital during this epidemic. Although these conversations are tough to initiate, when presented in a compassionate manner by physicians who know their patients well, these discussions are usually well received and appreciated.

We will be sending you a physician toolkit which includes:

• A custom form to guide you in this process on your respective Electronic Medical Records
  • Please download and use as the standard tool
  • The form includes information on how to approach the topic and resources for you and your patients to aid the process
• Suggested billing codes for phone counselling
• An ACP/GOC resource sheet to provide you with the tools specific to COVID-19
  • What Matters Most Conversation Guide
  • What Matters Most Patient Guide

2. Long Term Care (LTC) Physicians

It is imperative that LTC physicians revisit GOC discussions with your patients. LTC patients are extremely high risk, as many get sent to the ED for their illnesses (such as sepsis), however code status (Official DNR forms) is not clearly set, and thus it places the ER physicians and families with difficult decisions. Additionally, patients are at a tremendous risk for contracting the virus in the ED and bringing it back to LTC leading to massive outbreaks, thus having clear expectations outlined with the patients and families during this pandemic will be critical to keeping all of our patients and health care workers safe.

3. All other Physicians

You may be asked to provide guidance to individuals and families making these difficult decisions. Please review the documents provided above to help mentally prepare. All physicians share a responsibility to advocate for their patients. This is an important topic that must be addressed by all specialties of medicine. Please help in raising awareness and promote these discussions when possible.

We will be continuing to advocate for our patients to consider this important topic. Our task force will be contacting the media to inform the public and bring awareness and resources through multiple channels. We are working with you to make a difference in our community. Time to act is now. Thank you for your time and please be safe.

Yours sincerely,
Members of the Advanced Care Planning and Goals of Care Task Force