Starting the Conversation

By Melissa Moore
Friday, November 11, 2016

For physicians, knowing a patient’s end-of-life wishes is just the beginning of a future care and patient preferences discussion.

A lack of training in advance care planning during medical school or residency may lead to a level of discomfort surrounding the difficult and delicate discussion with patients about end-of-life healthcare decisions. However, it is the patient who ultimately suffers when physicians do not address this aspect of care.

“As doctors and trusted partners in our patients’ health, it’s our job to help patients understand why it’s important to think about these issues now and inform family members of decisions,” says Vipul Bhatia, MD, Medical Director for Post-acute Services at WellSpan Health. “Research shows that patients want their physicians to talk with them about end-of-life decisions.”

Horizon Planning®

For the past few years, a team at WellSpan has been developing and implementing an advance care planning program known as Horizon Planning®. The program involves the patient, their family and their physician learning and talking about the wishes of the patient regarding healthcare decisions that might need to be made should a medical crisis arise that leaves the patient unable to make their own healthcare decisions. It is an opportunity to consider those decisions ahead of time and then document the patient’s preferences.

WellSpan uses a team approach in helping patients with Horizon Planning®. Physicians, nurses and health coaches, like Amy Mummert (above), are all important players in guiding patients through the process.

Dr. Bhatia says that more than 825 WellSpan physicians have been introduced to Horizon Planning® and the program has been a focus of a pilot group of WellSpan primary care practices over the past 15 months. WellSpan is also working with community coalitions and organizations to encourage people to have a conversation with family or friends and their primary care provider about advance care planning.

The Conversation

“Advance care planning is a spectrum,” Dr. Bhatia says. “For example, when a healthy 18-year-old comes to a primary care physician for the first time, the physician can ask the patient who should make medical decisions in the event of an unexpected accident. It would also be important to follow up and make sure that once someone is identified, the patient had a conversation with that person about the patient’s wishes. This is a basic approach to advance care planning that can be asked of every patient who comes to the provider.”

Those with chronic illnesses who are becoming sicker and admitted to the hospital more frequently will require a more detailed level of planning. The degree of planning increases again when patients receive an end-stage diagnosis.

The depth of conversation required for effective advance care planning differs from patient to patient.

Taking Time, Increasing Effectiveness

“The next step of effective advance care planning is to complete documents such as living wills, as well as file them in the medical record so that they can be accessed when needed in the future.”

For a WellSpan patient, their Horizon Plan® will be filed in their electronic health record. However, the conversation should not end there. A patient’s health changes and their view on life may change. The conversation about advance care planning should be ongoing and any documents revised as necessary.

“We want every patient — young and old, healthy and frail — to connect with the term Horizon Planning® and start thinking about future events,” Dr. Bhatia says. “The Horizon Planning® method incorporates all members of the care team to ensure a patient speaks with their family before completing documentation.”

To learn more about Horizon Planning®, visit