Advance Care Planning Getting the information needed to make informed choices about end-of-life treatments

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Advance Care Planning Getting the information
needed to make informed choices about end-of-life
treatments

• Learning objectives to meet the goals of
  Knowledge to Practice
• To provide evidence for the importance of
  initiating advance care planning discussions
• To outline ways discussions can be initiated
• To provide a guide to assist health care
  providers giving individuals direction for
  planning an advance directive
• To provide resources to aid in discussions and
  planning

Lakehead U N I V E R S I T Y
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CLARIFICATION OF THE TERMADVANCE CARE PLANNING

• A process of communication involving an
  individual and his/her family, loved ones, and
  health care providers
• May require several discussions for clarification
  and comprehension of relevant information
• Can be initiated while a person is healthy or
  when a person is experiencing a chronic or
  terminal illness
• Can involve both agency-based and community-based
  knowledge
• The person and their designated family
• Various health care providers
• Physician, nurses, social worker, pastoral care,
  and/or case manager
• Does not necessarily involve a lawyer or notary

Lakehead U N I V E R S I T Y
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CLARIFICATION OF THE TERMADVANCE CARE
DIRECTIVE

• Also referred to as an advance care plan
• A written or oral expression of the persons
  wishes for care if he/she
• becomes incapable of communicating or unable to
  give informed consent
• Can be prepared by a lawyer or by the individual
  person
• Trusting that his/her wishes will be respected
  to the extent that this is
• possible, the person chooses a substitute
  decision-maker or proxy (legal
• designation)
• Advance care directives should be revisited
  periodically to address changes
• in status of health, beliefs or values
• People change their minds with new experiences

Lakehead U N I V E R S I T Y
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CHALLENGES TO EFFECTIVE
ADVANCE CARE PLANNING

• Fear of facing issues concerning illness and
  death
• Difficulty in anticipating future wishes
• Not knowing the wishes, values and beliefs of a
  person prior to incapacity
• Dissonance of values within a family and/or with
  healthcare providers (i.e. culture
  religion)
• Lack of temporal systems to support advance care
  planning
• Confusing terminology (jargon, understanding
  complexity of treatments)
• Lack of user-friendly, affordable help and
  resources
• Ambiguity vague instructions

Lakehead U N I V E R S I T Y
Lakehead U N I V E R S I T Y
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BENEFITS TO EFFECTIVE ADVANCE CARE PLANNING

• Persons voice is heard
• Reduces anxiety about what lies ahead
• Comfort of having a greater sense of control
  over what may happen in the future
• Avoidance of unnecessary conflicts with family
  members and/or healthcare providers
• An opportunity to gain understanding and
  comprehension of decisions and consequences
• Gain appreciation on how treatment options will
  affect the individual on a personal level

Lakehead U N I V E R S I T Y
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• CAPACITY
• A central issue in advance care planning

• Adults are presumed capable unless proven
• otherwise
• Common law test for capacity
• Persons ability to understand the relevant
• information
• Persons ability to appreciate any reasonably
• foreseeable consequences of a decision
• Equating irrationality and incapacity is a
• common error

• Capacity may be transient and change over time
• Delirium
• Drug interaction
• Lack of sleep
• Strong emotions
• Depression
• Shock
• Denial
• Underlying illness
• Be aware that incapacity may only be temporary
• Reversible causes must be ruled out, treated, and
  reassessed

Capacity Assessment Outcomes (Capacity to Consent)
Full/Complete Partial Capacity Total Capacity
Lakehead U N I V E R S I T Y
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• POWER OF ATTORNEY FOR PERSONAL CARE

• Can appoint more than one person at any time
• Can be altered at any time as long as the person
  is capable
• Appointed person can resign at any time
• Designated power of attorney is required to
• Consider any wishes the current incapable person
  may have
• Consider the values and beliefs the incapable
  person held
• Consider whether the decision will improve
  quality of life or
• prevent it from becoming worse (risk/benefits)
• Produce documentation to health care providers
• regarding POA status in event of substitute
  decision-making

Lakehead U N I V E R S I T Y
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SUBSTITUE DECISION-MAKER
Hierarchical List under Provincial Legislation to
be used if a POA has not designated an individual

• If there is not a designated power of attorney
  for personal care, an individual needs to be
  chosen that will
• act in your best interest
• know you well
• be someone you trust
• be able to make decisions under
• stress

Your spouse, common-law spouse or partner Your
child (if they are 16 years of age or older) or
parent Your parent with right of access only
Custodial parents rank ahead of non-custodial
parents Your brother or sister Any other
relative by blood, marriage or adoption The
Office of the Public Guardian and Trustee - last
resort
Lakehead U N I V E R S I T Y
http//www.attorneygeneral.jus.gov.on.ca/english/f
amily/pgt/poa.pdf
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COMMUNICATION Points for Health Care Providers
to Consider When Discussing ACP

• Review, recognize and reflect on personal views
  of ACP
• Direct conversations to the older person
• Recognize the amount of details a person wants
• will vary with the individual
• Acknowledge cultural diversity
• Do not assume that communication difficulties
• equate to not understanding or not having
  anything
• to say
• ASK for help bring in appropriate assistance

Avoid Medical Jargon
Be Clear Direct
Allow Time for Reflection
Dont assume you understand ASK
Lakehead U N I V E R S I T Y
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STATEMENTS TO GET THE CONVERSATION STARTED
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QUESTIONS TO ANSWER IN ADVANCE CARE PLANNING
The point in not whether the decision is
reasonable or what the health care team feels is
most appropriate, rather whether it was reasoned,
based in reality and consistent with the persons
previously expressed values and beliefs.
Lakehead U N I V E R S I T Y
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ADVANCE CARE PLANNING GUIDE
Lakehead U N I V E R S I T Y
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HAVE YOU COMPLETED YOUR PLAN?

• PLANNING IS BRINING THE FUTURE INTO THE PRESENT
  SO THAT YOU CAN DO SOMETHING ABOUT IT NOW
• Alan Lakein

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REFERENCES

• Educating Future Physicians in Palliative and
  End-of-Life Care (EFPPEC). (2008). Facilitating
  Advance Care Planning An Interprofessional
  Educational Program Curriculum Materials. Ottawa
  EFPPEC.
• Government of Ontario. (2007). A Guide to Advance
  Care Planning. Retrieved on July 10, 2008 from
  http//www.culture.gov.on.ca/seniors/english/progr
  ams/advancedcare/dontappoint.shtml.
• Health Canada. (2006). Advance care planning the
  Glossary project Final report. Retrieved on July
  10, 2008 from
• http//www.hc-sc.gc.ca/hcs-sss/pubs/palliat/
  2006-proj-glos/index-eng.php.
• Ministry of the Attorney General Office of the
  Public Guardian and Trustee (2004). Powers of
  Attorney. Retrieved on July 10, 2008 from
  http//www.attorneygeneral.jus.gov.on.ca/english/f
  amily/pgt/poa.pdf.