Letters to the Editor - February 2016

Having worked as a primary care nurse practitioner (NP) for the past 20 years, as well as having just completed my doctoral work on advanced care planning, I was dismayed upon reading Drs Weinberg and Stason’s end-of-life (EOL) planning article1 in the December issue of Consultant, as they neglected to mention the importance of including the entire primary care team, not just the physician staff, in the EOL planning process.

Because a growing number of primary care patients are being seen regularly by both NPs and physician assistants, their advocacy for their patients and families is crucial in this area.2

In addition, while the authors do state that there is no consensus on the ideal time to begin these discussions, my research has shown the benefit of starting EOL discussions as soon as a patient enters adult primary care and begins making his or her own independent health care decisions, rather than waiting until there is advanced disease, a critical illness, or when EOL is imminent.3 By making these discussions a part of each regular primary visit early on the discomfort, anxiety and stress that both patient and provider may feel about engaging in these talks will be lessened, and patients will not feel overwhelmed by the process when their health becomes critical.

Finally, while the authors did discuss the benefits of having all advance directives fully available in the electronic medical record (EMR) so that all care providers would be aware of patient preferences, they did not mention the advantage of also discussing and including Medical Orders for Life-Sustaining Treatment (MOLST) forms as part of the EMR.4

Although I do agree for the most part with the authors’ discussion of the topic, I feel that these omissions are important points that need to be given consideration.

— Monica Dube, DNP, FNP-BC


1.     Weinberg N, Stason WB. End-of-life planning in primary care practice. Consultant. 2015;15(12):999-1005.

2.     Goodell S, Dower C, O’Neil E. Primary Care Workforce in the United States: The Synthesis Project Policy Brief No. 22. Princeton, NJ: Robert Wood Foundation; July 2011. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70613. Accessed January 18, 2016.

3.     Dube M, McCarron A, Nannini A. Advanced care planning complexities for nurse practitioners. J Nurs Pract. 2015;11(8):766-773.

4.     Institute of Medicine Committee on Approaching Death. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life: Key Findings and Recommendations. Washington, DC: Institute of Medicine: 2014. http://iom.nationalacademies.org/~/media/Files/Report%20Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf. Accessed January 18, 2016.


The authors reply:

We appreciate Dr Dube’s comments. 

The patients included in our study were among the sickest and most complex in the primary care physician’s practices. Typically, the physicians took principal roles in managing these patients. A critical element for patients and their families in making informed decisions about advanced directives included a clear understanding of their prognosis. This process is difficult even for experienced physicians. Most NPs in these practices were not trained for these types of assessments at the time of our study.

Responses to a patient’s questions about advanced directives was (and is) felt to be a multidisciplinary task that includes involved physicians, case managers, and social workers. We welcomed input from experienced NPs, even if they were not directly involved in establishing advanced directives. Moreover, NPs involved in skilled nursing facilities or hospices were capable of and did carry out these EOL discussions.

There was no consensus among the clinicians in our study as to the best time to have discussions of EOL care, except that it was better to have them when patients were clinically stable and were better able to make objective decisions than when they were acutely ill. EOL discussions at the end of routine visits was felt to be challenging, given time constraints and EMR requirements. Most doctors in our practices advocated conducting them during separate office consultations, even though Medicare did not reimburse for these visits during the time of our study.

The MOLST Program was in its infancy and was not yet established as routine during the period of our study. We did, however, make efforts to ease the burden of including advanced directives in EMRs and making these accessible to physicians in the emergency department or during hospital admissions. At the time of our study, however, EMR systems varied and were not uniform.

— Norman Weinberg, MD, and William B. Stason, MD, MSc