Executive Insight – How to Engage People in Advance Care Planning: Employing Motivational Interviewing to Overcome Barriers to Aligned Care in Advanced Illness

By Allan Zuckoff, PhD
VP, Clinical Program Development

Despite the well-known benefits of advance care planning (ACP) care aligned with an individual’s values and preferences all the way to the end, reduced burden on family, and overall impact on quality of life—most people report that they have not had a conversation with their physicians about end of life care decisions. Strikingly, this is true even for those who are elderly, coping with serious chronic illnesses, or at imminent risk of death.

Factors Impacting Advance Care Planning (ACP) Conversations

Physicians and Health Systems

• ƒPhysicians can hesitate to raise the topic with patients and families out of fear of upsetting or alarming them and concern about undermining hope or reducing their willingness to endure difficult treatments.
• Many physicians equate their patients’ death with their own failure, and as a result avoid discussing this as a possibility.
• ACP is not embedded in routine care in many settings, which creates time and systems barriers to these conversations.
• As a result, ACP conversations often happen less than a month before people die—too late to fully impact their advanced care treatment experience.
• They also typically occur during inpatient episodes, when people are in the midst of medical crises and thus unable to engage in optimal decision-making about future care.
• The time pressure created by conducting ACP conversations under these circumstances, as well as lack of training and the tendency to focus on specific procedures rather than on values and quality of life goals, frequently makes these conversations less effective than they would otherwise be.

Individuals and Families

• Talking about worsening illness, preferences for treatment when cure is no longer a possibility, and the kind of care that is and is not wanted at end of life can be sad and frightening.
• People may inaccurately view their desire to stay positive and hope for the best as incompatible with ACP conversations.
• Understanding of decisions they may face and options that may be available are often limited.
• People may question whether planning in advance for future medical care will have a meaningful impact on the care they receive, and their confidence in their ability to carry out such conversations may be low.
• For many families, planning for when their loved one’s illness advances can feel like a betrayal.
• Discussing difficult decisions and resolving potential conflicts may not be part of the family’s repertoire and managing interactions with medical providers can feel overwhelming.

Advance Care Planning is Complex Health Behavior Change

People vary in how ready they are to engage in ACP—to articulate their values, quality of life goals, and preferences for care; apply these values and preferences to future medical scenarios; select a trusted person to speak for them if they are unable to speak for themselves; document and communicate their decisions to family and their medical team; and revisit and revise their plans as circumstances and preferences change.

Motivational Interviewing

Motivational interviewing (MI) is a patient-centered, collaborative method for creating an empathic, affirming, and autonomy supportive relationship within which the individual can discover and express their own reasons and ability for change. MI recognizes that people change behavior when they perceive the change as important and feel confident of success. People weigh the benefits of change against the perceived costs, and the result is often a level of ambivalence that impedes progress.
When practicing MI, clinicians accept that ambivalence about change is normal, and that efforts to persuade people to engage in healthier behavior are often met with “resistance”—which is nothing more than the natural tendency to push back against pressure to change before we’re ready. Starting from the premise that we learn what we think as we hear ourselves speak, MI practitioners listen for, draw out, and selectively highlight individuals’ own expressions of desire, reasons, need, or ability to change. In this way, MI helps clinicians to evoke motivation for change through skillful cultivation of “change talk”.

Motivational Interviewing for Advance Care Planning

Motivational interviewing improves engagement and outcomes in health behavior change in both in-person and telehealth settings it’s a good fit for the end-of-life context. MI allows clinicians to enhance readiness for ACP. At Vital Decisions, Advance Care Alignment Specialists employ MI to engage people and their families into an ACP service and guide them through the process of developing, documenting, and sharing their advance care plan.

The dialogue below gives an example of how MI can be used to engage and support a person with advanced illness who is initially reluctant to participate in an ACP conversation.

I realize my condition is serious, but thinking
positive is keeping me going right now.

It’s very important that we don’t do anything that would take away your hope.

Yes. I don’t want to put my head in the sand, but I can’t let myself get overwhelmed.

You want to deal with the situation head on, as long as it doesn’t become too much all at once.

Well, I need to. If the worst happens, and my daughter doesn’t know what I want her to do…I just can’t do that to her.

You love her too much to let that happen.

I do. But when I bring this up she changes the subject. I need to talk to her about it, but I don’t want to upset her.

You want to find a way to talk with her about your wishes that wouldn’t be more than she could handle. So she can be prepared for anything.

That’s right. Can you help me with that?

That’s exactly what we do—help you express your wishes to the people who matter most, so everyone is on the same page. Are you ready to start?

Dr. Allan Zuckoff is Vice President, Clinical Program Development, at Vital Decisions. Allan is a psychologist who infuses clinical innovation into the design and execution of Vital Decisions’ Advanced Care Alignment programs. He specialized in motivational interviewing training, research, and practice for more than two decades at the University of Pittsburgh and is a member of the board of directors of the international Motivational Interviewing Network of Trainers (MINT). Most recently, Allan is the author of Finding Your Way to Change: How the Power of Motivational Interviewing Can Reveal What You Want and Help You Get There.