When patients with significant underlying comorbidities suffer life-threatening or serious complications at Indiana University Health, the palliative team is consulted. All too often, they find there is no advance directive in place.

“Patients undergo a thorough preoperative evaluation. But there is no process to counsel them on advance care plans,” says palliative care physician Shilpee Sinha, MD, FACP. Thus, difficult decisions often fall in the surrogate’s lap — or there is no named surrogate. “This causes significant distress and sometimes prolonged suffering,” says Sinha. “The family considers a comfort approach akin to ‘giving up’ on loved ones.”

To identify gaps in advance care planning, researchers retrospectively reviewed 400 charts of patients who had undergone an evaluation in a preoperative clinic in 2017 at two high-volume hospitals.1 “My clinical experience was validated by the study’s findings,” says Sinha. Just 16% of patients had an advance directive scanned into the EMR. Some patients reported completing an advance directive, but it was not available in the EMR.

“My motivation is to help bring advance care planning more upstream and avoid such decision-making in a critical setting,” says Sinha. This would allow patients to exercise autonomy in the form of a written advance directive. “Without adequate counselling and assistance in preparing advance directives, this may be compromised when they lose capacity,” says Sinha.

To bring advance care planning “upstream,” Sinha says the clinical team must allocate time and resources to it. This must be done before any major intervention (surgical or otherwise). These steps are needed:

• A trained facilitator should ask patients about their understanding of what an advance directive is, and whether they have created one;

• A designated member of the healthcare team should be made responsible for ensuring that existing or completed documents are scanned to the EMR in a well-identified location.

“Education is certainly a big part of this, as are developing policies after appropriate buy-in and understanding by all parties,” says Sinha.


1. Sinha S, Gruber RN, Cottingham AH, et al. Advance care planning in a preoperative clinic: A retrospective chart review. Gen Intern Med 2019; Jan 2. doi: 10.1007/s11606-018-4744-8 [Epub ahead of print].