By Jim Parker | April 16, 2020
Ryan Van Wert, M.D. is co-founder and CEO of Vynca, a technology company that offers solutions to health care organizations to support person-centered care by ensuring that patient preferences are captured, accessible and honored. In addition to his role at Vynca, Van Wert is a part-time clinical assistant professor at Stanford University.
In observance of National Healthcare Decisions Day, Van Wert shared his insights with Hospice News about the importance of advance care planning and the impact of COVID-19.
What have you been observing in terms of the response to the pandemic by health care organizations?
As a pulmonary critical care physician, the past few weeks have been like nothing I have experienced in my career. Health care organizations across the country have been working to rapidly implement new processes and workflows to screen, diagnose and treat patients with COVID-19, as well as planning ahead for the potential increase in need for inpatient and critical care resources. It has been remarkable to see my colleagues rally together, working around the clock to prepare for and manage this extraordinary situation.
As health care organizations shift their focus toward responding to the pandemic, why should advance care planning remain a priority?
I’ve always said advance care planning needs to happen early and often. What we are experiencing now is unfortunately proving why. Most Americans prefer comfort focused care when faced with serious, life-limiting illness. With COVID-19, the risk of requiring life support increases dramatically with age and chronic illness. Without an advance care plan, these individuals are extremely vulnerable to being placed on a ventilator. This both denies the individual the right to choose the care they want, and takes up an increasingly precious resource. With the real crisis of ventilator and intensive care unit (ICU) shortages on the horizon, this is unacceptable. Advance care planning, when done properly, starts with a high-quality conversation around values, choices, and goals, and any documented care preferences should reflect these. Knowing and having these available in times like these (and really anytime), can help determine if an individual, who has COVID-19 or not, needs to go to the hospital, or if they should receive comfort care. And these hospitals need to be able to readily access advance care planning documents.
Along with hand washing and staying home, clinicians are urging people to engage in advance care planning conversations with loved ones, and understand and document what kind of care they may want at end-of-life. COVID-19 could result in 10 million to 34 million hospital visits, and we are already seeing convention centers in New York and Chicago being turned into makeshift hospitals. One-fifth of these patients will require intensive care. The United States has an estimated number of 45,000 ICU beds – just a moderate outbreak would require 200,000 ICU beds. And as we all know, the numbers continue to climb daily, and this is not just infecting older adults and those with underlying medical conditions.
How are health care organizations responding to these changing conditions?
I’m having more and more conversations with health care organizations and state authorities looking at ways to quickly implement and standardize advance care planning. I’m also seeing some adapt their plans to better respond to COVID-19. Our client, Spectrum Health, based in Grand Rapids, Mich., developed a condensed advance care planning packet and virtual training to raise community awareness of the need for proactive advance care planning conversations. Their goal is to put plans in place, before an individual becomes ill.
The condensed packet focuses on designating a patient advocate, as well as specific treatment preferences, such as code status and ventilator support. It also provides individuals with the opportunity to express what is most important to them, as well as what they consider to be unacceptable outcomes.
These decisions are not only important during the COVID-19 pandemic, but also beneficial for future health care decisions. Their initial focus is on supporting high risk-populations in their community by concentrating on approximately 50 skilled nursing facilities and home health agencies, with plans to expand.
How does the increase in telehealth during the pandemic influence organizations’ ability to engage in advance care planning with their patients?
We’ve seen [U.S. Centers for Medicare & Medicaid Services (CMS)] loosen the restrictions to encourage the use of telehealth and eliminate exposure and potential spread of the virus. This includes palliative care and hospice. We’re seeing more organizations make the shift from in-person visits to telehealth visits. Those that are not set up on a telehealth platform are leveraging conference call services, such as Zoom, that incorporate calling plus video capabilities.
Some are leveraging telehealth to discuss and complete advance care plans. Historically advance care planning documents have been completed on paper, but there are obviously many barriers when having these conversations and trying to complete documents that require signatures. In response, we’ve developed our COVID-19 Emergency ACP eRegistry solution, allowing health care organizations to quickly stand up a solution to support the digital creation (including eSignature) and access of documents. Having these care plans readily available helps clinicians understand treatment preferences, and avoid wasting unnecessary hospital resources.
What should hospice and palliative care providers be doing in regards to advance care planning during this pandemic?
National Healthcare Decisions Day this year truly hits home for many. It’s important to encourage your patients to create and share their advance care plans. It’s important to make sure you and your loved ones also have these plans in place. Know their preferences, and make sure that they know yours. Know what resources are out there. American Academy of Hospice & Palliative Medicine (AAHPM), the Center to Advance Palliative Care (CAPC) , and the National Hospice & Palliative Care Organization (NHPCO) are a few of the many organizations offering great clinician facing COVID-19 resources. Both Five Wishes and Prepare™ for Your Care provide free COVID-19 resources and advance directives. The time to start thinking about this and taking action is now.