Advance care planning documents, including advance  directives and POLST forms, allow individuals to express their wishes for  end-of-life care. Advance Directive

An advance directive is a written instruction recognized under state law  and relating to the provision of health care when an individual is  incapacitated. The most  common advance directive documents are living wills and health care  power of attorney. For these individuals, their current health status indicates  the need for medical orders. Challenges to Advance Care Planning Include Understanding the Types of Documents and Ensuring Access to Completed Documents

Based on our interviews with officials from national stakeholder  organizations, state agencies and stakeholder organizations in selected  states, and articles we reviewed, we identified two broad challenges to  advance care planning: (1) a lack of understanding about advance care  planning, including how to initiate conversations about advance care  planning and how to complete and follow advance care planning  documents; and (2) ensuring access to completed documents. In addition to challenges related to  having advance care planning conversations, individuals and providers  may not understand that filling out the document is voluntary or how to complete and follow the advance care planning document, according to  officials from national stakeholder organizations and officials in the four  selected states. Various Strategies Used in Selected States to Improve Individuals’ and Providers’ Understanding of and Access to Advance Care Planning Documents

In our four selected states—California, Idaho, Oregon, and West  Virginia—state agencies and state stakeholder organizations pursued  various strategies to improve individuals’ and providers’ understanding of  advance care planning documents, as well as to improve their access to  completed advance care planning documents. In addition, the  organizations created EMS protocols related to accessing individuals’  wishes during emergencies. Selected States’ Strategies to Improve Access to Completed Documents Included Interoperability between Electronic Health Records and Registries

Officials from state agencies and stakeholder organizations in our  selected states utilized strategies to improve access to current advance  care planning documents, including better interoperability between EHRs  and a state registry, and access to completed documents stored in  registries. Regarding acceptance of out-of-state advance care planning  documents—that is, the portability of documents across state lines—we  found that all four selected states have statutes that address the validity  of advance care planning documents executed in another state. Agency and Third Party Comments

We provided a draft of this report to the Department of Health and Human  Services. HHS provided technical comments, which we incorporated as  appropriate. Appendix II: Types of Information Found on a POLST Form

Physician orders for life-sustaining treatment (POLST) forms are different  in each state, and the order of the sections or the options within a section  may differ.
Why GAO Did This Study

Many individuals receive medical care for a serious or life-limiting condition during the last months of life, which may involve making difficult decisions about life-sustaining treatment. Advance care planning helps ensure that physicians, families, and friends have documentation outlining individuals' wishes under these circumstances.
GAO was asked to identify issues related to completing and accessing advance care planning documents. This report describes, among other things, (1) the challenges individuals and providers face completing and accessing the documents, and (2) selected states' strategies for improving individuals' and providers' understanding of and access to advance care planning documents.
GAO reviewed documents and interviewed officials from national stakeholder organizations involved in advance care planning or aging issues, and conducted a literature review of relevant articles published from January 2012 to April 2018 in peer-reviewed and other publications. In addition, GAO interviewed officials from state agencies and stakeholder organizations in California, Idaho, Oregon, and West Virginia. GAO selected those four states because they were active in encouraging advance care planning and had registries for completed documents that were in different stages of development.
The Department of Health and Human Services, states, and stakeholders provided technical comments on a draft of this report, which GAO incorporated as appropriate.

What GAO Found

Advance care planning documents—including advance directives and physician orders for life sustaining treatment (POLST)—allow individuals to express their wishes for end-of-life care. Advance directives, which include living wills and health care power of attorney, provide direction regarding care when an individual becomes incapacitated. POLST documents are appropriate for seriously ill individuals whose health status indicates the need for medical orders to be documented in their medical records.
Stakeholders from national organizations and officials in the four states GAO selected to review cited several challenges—affecting both individuals and health care providers—related to the use of advance care planning documents. In particular, they noted a lack of understanding about how to complete the documents and how to initiate conversations about advance care planning. They also cited challenges related to the difficulty of ensuring access to completed documents when needed, such as in an emergency situation.
Officials from state agencies and stakeholder organizations in the four selected states reported pursuing various strategies to improve understanding of advance care planning documents by conducting education efforts for individuals and providers. In addition, the states utilized strategies to improve access to completed documents, such as improving the electronic exchange of information between health records and a state registry, which is a central repository intended to improve access to the documents. Further, stakeholder officials reported strategies related to the acceptance of out-of-state advance care planning documents; all four selected states had statutory provisions that address the validity of documents executed in another state.