Journal of General Internal Medicine

, Volume 27, Issue 4, pp 445–451 | Cite as

Missed Opportunities for Advance Care Planning Communication During Outpatient Clinic Visits

  • Sangeeta C. AhluwaliaEmail author
  • Jennifer R. Levin
  • Karl A. Lorenz
  • Howard S. Gordon
Original Research



Early provider–patient communication about future care is critical for patients with heart failure (HF); however, advance care planning (ACP) discussions are often avoided or occur too late to usefully inform care over the course of the disease.


To identify opportunities for physicians to engage in ACP discussions and to characterize physicians’ responses to these opportunities.


Qualitative study of audio-recorded outpatient clinic visits.


Fifty-two patients ≥ 65 years recently hospitalized for HF with one or more post-discharge follow-up outpatient visits, and their physicians (n = 44), at two Veterans Affairs Medical Centers.


Using content analysis methods, we analyzed and coded transcripts of outpatient follow-up visits for 1) patient statements pertaining to their future health or their future physical, psychosocial and spiritual/existential care needs, and 2) subsequent physician responses to patient statements, using an iterative consensus-based coding process.


In 13 of 71 consultations, patients expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians responded by terminating the conversation, hedging their responses, denying the patient’s expressed emotion, or inadequately acknowledging the sentiment underlying the patient’s statement.


Physicians often missed the opportunity to engage in ACP despite openers patients provided that could have prompted such discussions. Communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses; in order to successfully leverage opportunities to engage in ACP discussions.


qualitative research advance care planning heart failure physician-patient communication 


Funding Sources

This work was supported in part by #ECV-02-254 (PI: Gordon) from the United States Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service. The views expressed in the article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Ahluwalia is supported by an Office of Academic Affiliations’ VA Associated health Postdoctoral Fellowship Program at the VA Greater Los Angeles HSR&D Center of Excellence

Prior Presentations

Presented as a paper at the 2011 Society of General Internal Medicine Annual Meeting, May 4th-May 7th 2010, Phoenix, AZ

Conflict of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Sangeeta C. Ahluwalia
    • 1
    Email author
  • Jennifer R. Levin
    • 2
  • Karl A. Lorenz
    • 2
    • 3
  • Howard S. Gordon
    • 4
    • 5
  1. 1.Center for the Study of Healthcare Provider BehaviorVA Greater Los Angeles Healthcare SystemLos AngelesUSA
  2. 2.Veterans Administration Greater Los Angeles Healthcare SystemLos AngelesUSA
  3. 3.Geffen School of Medicine at UCLALos AngelesUSA
  4. 4.Jesse Brown Veterans Affairs Medical Center and VA Center for Management of Complex Chronic CareChicagoUSA
  5. 5.Sections of General Internal Medicine and Health Promotion Research, Department of MedicineUniversity of Illinois at Chicago College of MedicineChicagoUSA

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