Comment on: “Advance” care planning reenvisioned

See the Reply by Moody et al. in this issue. The COVID-19 pandemic has brought into sharp focus challenges, fragility, and uncertainties of advance care planning (ACP) discussions with people living life-limiting illnesses. ACP programs have been adapted to accommodate (e.g., “Serious Illness Conversation guide” “Vital Talk” * More information about these can be found https://covid19.ariadnelabs.org/serious-illness-care-program-covid-19-response-toolkit/ https://www.vitaltalk.org/guides/covid-19-communication-skills/ ) underscore importance timely for patient management. If conducted well, facilitate a holistic, collaborative, person/family-centric approach addressing wishes preferences before onset rapid illness deterioration. In context COVID-19, however, there concern that on process goals completion rates ACP), conflation Do Not Attempt Cardiopulmonary Resuscitation decisions,1 general uncertainty surrounds discussions,2 led anticipated benefits being questioned. her recent editorial “‘Advance’ reenvisioned,”3 expressed similar concerns makes case “reconsider[ing] whether current approaches are realistic most individuals” their family because “in life, it is rare make decisions far an event, yet medicine, we ask patients do just that.” reenvisioning proposes calls adoption “adaptive planning”; responsive flexible takes consideration dynamism clinical practice which what “ultimately matters made moment(s) response unfolding events.” We provide further reflections planning” may look like (i) outlining hybrid ACP; (ii) proposing theoretical framework accompany implementation approach. support Moody's sentiment able adaptive, in-the-moment decisions. Indeed, value supported evidence frail older people4 individuals multiple sclerosis5 difficulties, instability, (sometimes) perceived irrelevance making future based incomplete or hypothetical highlighted. A approach, embraces as multicomponent resists false dichotomy seeing either moment, future. Rather, contend virtues combined whereby opportunities given plan near One benefit allowing opportunity allows health professionals maintain trust families engaging in, regularly reviewing, parallel plans two sets made; one stability improvement, another deterioration.6 coalescence types mutually enrich another, enhancing communication ways prepare all involved difficult future, whilst maintaining flexibility adaptive moment.” Effectively implementing high-quality ACP, requires understanding how conversations occur systematic, skilled, consistent manner (and across) services. This serious “wrap-around” preconditions underpin multicomponent, ACP. believe best way through socioecological “lens” “whole systems strategic approach” adopted.7 appreciates exist multiple, interconnected elements reside at different societal organizational levels influence individual, interpersonal, organizations, systems, cultural) necessary consider before, during, after implementing/having discussions.7 Drawing from contemporary reviews research studies contexts nursing homes, sclerosis patients, practice, palliative care), Table 1 provides summary (yet not exhaustive) list multilevel considerations when propose any context. • Healthcare professionals, knowledgeable trajectory/prognosis affect decisions5, 8 Understanding demographics previous experiences family9, 10 of, having skills confidence effectively engage ACP5, 7, 9 Considering individual's readiness/willingness participate conversations5, 8, Developing strong, trusting relationship family8, Seeing process; revisiting/repeating where necessary7 Communication training education provided workforce5, Embed evaluate relative effectiveness ACP7 “normalization” standardization everyday within between services/care settings7-9 Efficient I.T./administration storage, retrieval, prompts ACP7-9 Be aware adequately adapt to, person's socio-cultural beliefs backgrounds7, structural legal constraints related Adaptive autonomy moment” important. However, should integrated preparing When lens factors impacting considered. None authors conflicts interest declare. All substantial contributions conception design letter approved final version published. Andy Bradshaw writing process, were drafting article revising critically important intellectual content. No sponsor's sponsor role