{"id":5465,"date":"2026-04-17T17:33:45","date_gmt":"2026-04-17T17:33:45","guid":{"rendered":"http:\/\/homecares.net\/?p=5465"},"modified":"2026-04-17T17:33:45","modified_gmt":"2026-04-17T17:33:45","slug":"advance-care-planning-a-critical-examination-of-efficacy-and-evolving-perspectives","status":"publish","type":"post","link":"https:\/\/homecares.net\/?p=5465","title":{"rendered":"Advance Care Planning: A Critical Examination of Efficacy and Evolving Perspectives"},"content":{"rendered":"<p>Several years ago, during a presentation to an audience predominantly composed of palliative care professionals, a simple yet potent question was posed: &quot;How often do you find yourselves, in the care of your patients, saying to yourselves something like &#8216;Thank the stars this patient has a healthcare directive (HCD)&#8217;?&quot; The response was telling \u2013 a sea of shrugs and hesitant agreements, with few indicating routine reliance on the utility of HCDs. This observation, though anecdotal, underscored a palpable disconnect between the perceived importance of Advance Care Planning (ACP) and its tangible impact in clinical practice. This sentiment has been amplified in recent months by a significant debate within the hospice and palliative care communities, ignited by Dr. Sean Morrison&#8217;s provocative editorial in the <em>Journal of Palliative Medicine<\/em>, titled &quot;Advance Directives\/Care Planning: Clear, Simple, and Wrong.&quot;<\/p>\n<p>The ongoing discourse surrounding ACP has prompted considerable reflection among practitioners and researchers alike. Dr. Drew Rosielle, a palliative care physician and founder of Pallimed, has been among those grappling with Morrison&#8217;s critique. His recent writings delve into the complexities of ACP, suggesting a fundamental disagreement regarding its definition and, consequently, its measurable effectiveness. This article aims to explore the core arguments presented by Dr. Morrison and the subsequent analysis by Dr. Rosielle, providing a comprehensive overview of the current state of ACP, its historical context, and the implications of this critical reassessment.<\/p>\n<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_82_2 counter-hierarchy ez-toc-counter ez-toc-grey ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">Table of Contents<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/homecares.net\/?p=5465\/#The_Genesis_of_Doubt_Dr_Morrisons_Challenge\" >The Genesis of Doubt: Dr. Morrison&#8217;s Challenge<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/homecares.net\/?p=5465\/#Defining_the_Divide_The_%22Big_Tent%22_vs_The_%22Narrow_Definition%22_of_ACP\" >Defining the Divide: The &quot;Big Tent&quot; vs. The &quot;Narrow Definition&quot; of ACP<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/homecares.net\/?p=5465\/#The_Lack_of_Evidence_for_Formal_Directives\" >The Lack of Evidence for Formal Directives<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/homecares.net\/?p=5465\/#Examining_%22Congruence%22_and_Observational_Data\" >Examining &quot;Congruence&quot; and Observational Data<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/homecares.net\/?p=5465\/#A_Shift_in_Focus_The_Palliative_Benefit_of_Reducing_Suffering\" >A Shift in Focus: The Palliative Benefit of Reducing Suffering<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/homecares.net\/?p=5465\/#Broader_Implications_and_Future_Directions\" >Broader Implications and Future Directions<\/a><\/li><\/ul><\/nav><\/div>\n<h3><span class=\"ez-toc-section\" id=\"The_Genesis_of_Doubt_Dr_Morrisons_Challenge\"><\/span>The Genesis of Doubt: Dr. Morrison&#8217;s Challenge<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Dr. Sean Morrison&#8217;s editorial, published in May 2021, represented a stark challenge to the long-held assumptions about the value of Advance Care Planning. He presented a sobering assessment of the extensive research and financial investment poured into ACP over decades, totaling hundreds of millions of dollars in taxpayer money through NIH and PCORI funding, alongside substantial foundation contributions. Despite this immense effort, Morrison argued, the evidence base for ACP&#8217;s effectiveness remains alarmingly thin.<\/p>\n<p>&quot;As of May 2018, 80 systematic reviews of advance care planning covering &gt;1660 research studies had been published and the National Institutes of Health and the Patient-Centered Outcomes Research Institute had funded &gt;750 research studies at a cost of &gt;$300 million in taxpayer money (an average of $1 million\/year). Foundations have spent untold millions,&quot; Morrison stated in his editorial. He further elaborated that &quot;The &gt;1660 studies and 80 systematic reviews on advance directives\/care planning have produced only limited and low-quality evidence that advance directives\/care planning can actually result in changes in patient, family, clinical, utilization, or financial outcomes.&quot;<\/p>\n<p>Morrison&#8217;s assertion that &quot;the majority of high-quality research has failed to find a strong link between advance directives\/care planning and outcomes of importance&quot; is a significant indictment. Compounding this, he noted that despite 30 years of diverse interventions, &quot;two-thirds of adults do not have an advance directive \u2013 an imperfect yet reasonable surrogate for occurrence of an advance care planning discussion.&quot; This statistic, he implied, suggests a systemic failure not only in demonstrating ACP&#8217;s efficacy but also in its widespread adoption, even among those who might theoretically benefit.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"Defining_the_Divide_The_%22Big_Tent%22_vs_The_%22Narrow_Definition%22_of_ACP\"><\/span>Defining the Divide: The &quot;Big Tent&quot; vs. The &quot;Narrow Definition&quot; of ACP<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Dr. Drew Rosielle, in his commentary on Morrison&#8217;s editorial, posits that a significant reason for the controversy surrounding ACP critiques stems from differing interpretations of what ACP actually entails. He suggests that some clinicians employ a broad, or &quot;Big Tent,&quot; definition, encompassing any clinical activity related to discussing the future with patients. This includes prognostic discussions, preparing patients for future decisions, and general goals of care conversations.<\/p>\n<p>Conversely, Rosielle argues that critics like Dr. Morrison are likely referring to a more &quot;narrow definition of ACP,&quot; specifically focusing on the completion of Health Care Directives (HCDs) and the clinical and healthcare discussions directly associated with their education and completion. This distinction is crucial, as it reframes the debate from a wholesale rejection of future-oriented discussions with seriously ill patients to a more targeted critique of the effectiveness of formal documentation processes.<\/p>\n<p>Rosielle emphasizes that he is not criticizing the fundamental importance of discussing prognosis and future care with seriously ill patients. As a physician, he asserts a professional obligation to engage in these conversations to enable informed decision-making. His concern lies less with <em>whether<\/em> these discussions should occur and more with <em>how<\/em> they can be conducted more effectively, compassionately, and accessibly. This aligns with the sentiment expressed at the aforementioned palliative care talk, where attendees readily acknowledged the routine helpfulness of realistic discussions about the future, even if they rarely found formal HCDs to be the primary driver of that benefit.<\/p>\n<p>It is also important to clarify what this debate does <em>not<\/em> primarily concern. Physician Orders for Life-Sustaining Treatments (POLSTs), while related to advance care planning, operate under a different framework and are not the central focus of this critique, although their evidence base also warrants scrutiny. Similarly, initiatives like Ariadne Labs&#8217; Serious Illness Care project, which are rigorously studying their interventions in various settings and advocating for evidence-based implementation, are distinct from the broader, historically population-wide adoption of ACP without commensurate evidence.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"The_Lack_of_Evidence_for_Formal_Directives\"><\/span>The Lack of Evidence for Formal Directives<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Rosielle&#8217;s analysis supports Dr. Morrison&#8217;s contention that the evidence supporting the efficacy of formal ACP, particularly the completion of HCDs, is surprisingly weak. He highlights that ACP was integrated into healthcare as an innovation without the rigorous scrutiny typically demanded for other medical advancements, such as Left Ventricular Assist Devices (LVADs). The notion that ACP is inherently beneficial has become so deeply entrenched that significant resources have been allocated to studying <em>how<\/em> to increase ACP completion, rather than definitively proving <em>that<\/em> it improves patient-centered outcomes.<\/p>\n<figure class=\"article-inline-figure\"><img src=\"https:\/\/blogger.googleusercontent.com\/img\/b\/R29vZ2xl\/AVvXsEj0FBiZ21iWIVBu2sSEQm-RoQWItUYhNeUGPxlg2fgdrizf9tqKQysWlOv7GQV0sYgLIBOoSGkcUX2Zq5rbmdsSNjcrh93mJs3tQZLuEjUq2QpqnOmgoyQOaGGdH2QUAUxRalATtQ\/w1200-h630-p-k-no-nu\/ADvance+Care+Planning.png\" alt=\"Advance Care Planning? Meh. - Part 1\" class=\"article-inline-img\" loading=\"lazy\" decoding=\"async\" \/><\/figure>\n<p>Much of the existing ACP research, while methodologically sound in its pursuit of implementation strategies, operates under the assumption that helping patients complete ACP documents is inherently beneficial. Rosielle cautions against this assumption, stating, &quot;I am claiming that it&#8217;s high quality work which seems to assume we are benefitting patients by helping them do ACP yet we don&#8217;t actually yet know that.&quot; He acknowledges that individual patients may indeed benefit from ACP, but argues that this anecdotal evidence does not justify its widespread implementation as a routine, integral part of medicine or as a public health intervention, given the substantial investment of time and resources.<\/p>\n<p>Dr. Morrison&#8217;s core thesis, as interpreted by Rosielle, is not that ACP has &quot;never helped anyone,&quot; but rather that &quot;ACP is not worth the time\/money\/effort that has been spent on it as a public health intervention.&quot;<\/p>\n<h3><span class=\"ez-toc-section\" id=\"Examining_%22Congruence%22_and_Observational_Data\"><\/span>Examining &quot;Congruence&quot; and Observational Data<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>A key area of ACP research has historically focused on &quot;congruence&quot;\u2014whether patients who engage in ACP activities receive care aligned with their stated preferences. Early discussions often centered on patient autonomy and ensuring individuals received what they desired. However, Rosielle points out a critical flaw: there is a dearth of high-quality research demonstrating that ACP actually improves congruence.<\/p>\n<p>He cites two examples:<\/p>\n<ul>\n<li><strong>The Melbourne Study (2010, <em>BMJ<\/em>)<\/strong>: This comprehensive ACP intervention in high-risk hospitalized older patients appeared to improve &quot;congruence.&quot; However, a closer examination revealed that the intervention group had better documentation of their wishes, making it easier to <em>prove<\/em> congruence, rather than necessarily demonstrating that their care was actually more aligned with their preferences. The study did not definitively show that the ACP intervention changed any patient care.<\/li>\n<li><strong>Respecting Choices ACP Model RCT<\/strong>: This randomized controlled trial, involving 300 high-risk patients (severe heart failure or on dialysis), found no improvement in congruence even with a highly regarded ACP model. The study&#8217;s failure to demonstrate a difference in this vulnerable population underscores the challenges in proving the effectiveness of ACP interventions.<\/li>\n<\/ul>\n<p>Furthermore, Rosielle addresses the extensive body of research showing associations between having an HCD and outcomes like increased likelihood of DNR orders, longer hospice enrollment, and shorter ICU stays at the end of life. He argues that nearly all of this research is observational and susceptible to significant confounding factors. Patients who are more inclined to participate in ACP are likely already predisposed to desiring less intensive end-of-life treatments. Therefore, &quot;having a HCD may just be a proxy for also being disinclined to want &#8216;invasive&#8217; EOL treatments,&quot; and the <em>process<\/em> of completing the HCD may not be the causal factor in care decisions. This is particularly evident when prospective, controlled research, even using validated tools, struggles to demonstrate patient-centered benefits beyond increased ACP documentation.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"A_Shift_in_Focus_The_Palliative_Benefit_of_Reducing_Suffering\"><\/span>A Shift in Focus: The Palliative Benefit of Reducing Suffering<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>While agreeing with much of Dr. Morrison&#8217;s critique regarding the evidence for traditional ACP outcomes, Rosielle diverges on one significant point: the potential for ACP to be abandoned wholesale as a clinical and research endeavor. He argues that there is one under-researched domain where ACP may indeed offer substantial benefits: its palliative effect in reducing iatrogenic emotional suffering.<\/p>\n<p>Rosielle contends that healthcare systems have, over decades, inadvertently placed immense emotional burdens on grieving families by deferring critical end-of-life decisions to them. This has led to significant suffering, and ACP, he suggests, could serve as a mechanism to mitigate this. He points to the Melbourne Study again, which, despite lacking clear evidence of other benefits, did report &quot;decreased stress and anxiety symptoms in family members&quot; who participated in the ACP process.<\/p>\n<p>This perspective resonates with Ira Byock&#8217;s sentiment: &quot;I have an advance care directive not because I have a serious illness but because I have a family.&quot; Rosielle expresses frustration that this crucial outcome \u2013 the reduction of suffering for patients and families \u2013 has not been a primary focus of ACP research. He proposes that ACP could be investigated as a &quot;suffering-reducing, meaning-making intervention,&quot; analogous to approaches like Dignity Therapy.<\/p>\n<p>However, Rosielle is careful not to prematurely shift the justification for ACP solely to suffering reduction. He cautions against putting the cart before the horse, stating, &quot;It&#8217;s premature to say that. We can&#8217;t put the cart before the horse. ACP may yet be worthless as a broadly enacted healthcare intervention, and we should continue to consider any benefits hypothetical until proven otherwise.&quot;<\/p>\n<h3><span class=\"ez-toc-section\" id=\"Broader_Implications_and_Future_Directions\"><\/span>Broader Implications and Future Directions<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>The debate sparked by Dr. Morrison&#8217;s editorial and explored by Dr. Rosielle has significant implications for how advance care planning is perceived, researched, and implemented. It highlights the critical need for:<\/p>\n<ul>\n<li><strong>Clearer Definitions:<\/strong> Establishing consensus on what constitutes ACP is paramount for designing meaningful research and clinical interventions.<\/li>\n<li><strong>Rigorous Outcome Measurement:<\/strong> Future ACP research must move beyond correlational studies and focus on demonstrating tangible improvements in patient and family well-being, not just process measures.<\/li>\n<li><strong>Exploration of Novel Benefits:<\/strong> Investigating the palliative and emotional support aspects of ACP, as suggested by Rosielle, could unlock its true potential.<\/li>\n<li><strong>Evidence-Based Implementation:<\/strong> Any widespread adoption of ACP should be guided by robust evidence, rather than assumption.<\/li>\n<\/ul>\n<p>The ongoing conversation signifies a maturing of the field, moving from unquestioning acceptance to a more critical and evidence-informed approach. The ultimate goal remains to ensure that all patients, especially those facing serious illness, receive care that is aligned with their values and preferences, delivered with compassion and clarity. The effectiveness of ACP in achieving this goal, however, is still very much a subject of active and necessary inquiry.<\/p>\n<!-- RatingBintangAjaib -->","protected":false},"excerpt":{"rendered":"<p>Several years ago, during a presentation to an audience predominantly composed of palliative care professionals, a simple yet potent question was posed: &quot;How often do you find yourselves, in the care of your patients, saying to yourselves something like &#8216;Thank the stars this patient has a healthcare directive (HCD)&#8217;?&quot; The response was telling \u2013 a &hellip;<\/p>\n","protected":false},"author":1,"featured_media":5464,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[90],"tags":[311,20,94,290,550,93,280,1114,92,91,1115,312],"newstopic":[],"class_list":["post-5465","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-palliative-hospice-care","tag-advance","tag-care","tag-comfort-care","tag-critical","tag-efficacy","tag-end-of-life","tag-evolving","tag-examination","tag-hospice-care","tag-palliative-care","tag-perspectives","tag-planning"],"_links":{"self":[{"href":"https:\/\/homecares.net\/index.php?rest_route=\/wp\/v2\/posts\/5465","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/homecares.net\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/homecares.net\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/homecares.net\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/homecares.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=5465"}],"version-history":[{"count":0,"href":"https:\/\/homecares.net\/index.php?rest_route=\/wp\/v2\/posts\/5465\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/homecares.net\/index.php?rest_route=\/wp\/v2\/media\/5464"}],"wp:attachment":[{"href":"https:\/\/homecares.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=5465"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/homecares.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=5465"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/homecares.net\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=5465"},{"taxonomy":"newstopic","embeddable":true,"href":"https:\/\/homecares.net\/index.php?rest_route=%2Fwp%2Fv2%2Fnewstopic&post=5465"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}