Advance Care Planning in Cognitively Impaired Older Adults

Listen to the lively podcast to hear an informal conversation between all eight authors: practical issues related to advance care planning  in older adults with cognitive impairment. 

Authors: Jane deLima Thomas MD, Sandra Sanchez‐Reilly MD, MSci, Rachelle Bernacki MD, MS, Lynn O’Neill MD, Laura J. Morrison MD, Jennifer Kapo MD, Vyjeyanthi S. Periyakoil MD, Elise C. Carey MD

First published: 11 September 2018



Intended audience: Medical students, doctors-in-training and practice as well as inter-professional clinicians caring for seriously ill patients.
How to use this podcast: 
a. Read the Palliative Practice Pointer article in JAGS
b. Listen to this podcast for further discussion about the topic, to hear about real-life situations that highlights clinical nuances. You can listen on the browser (make sure computer speaker is on and the volume is turned up) or download it into your smartphone using iTunes or a comparable program.


Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision‐making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision‐makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual‐, clinician‐, and system‐related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision‐makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people’s wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision‐making capacity, identifying surrogate decision‐makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care.

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