Advance Care Planning

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Advance Care Planning

• Regina Mc Quillan

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Advance care planning

• What?
• Who?
• Why?
• When?
• Where?

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Medical Council Guidelines
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(No Transcript)
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Paragraph 41.1

• Sometimes patients might want to plan for their
  medical treatment in the event that they become
  incapacitated in the future. This might include
  an advance refusal of medical treatment and/or a
  request for a specific procedure. However, you
  are not obliged to provide treatment that is not
  clinically indicated for a particular patient

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Paragraph 41.2

• An advance treatment plan has the same ethical
  status as a decision by a patient at the actual
  time of an illness and should be respected on
  condition that
• The decision was an informed choice
• The decision covers the situation that has
  arisen
• The patient has not changed their mind

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Paragraph 41.3

• If there is doubt about the existence of an
  advance care plan, the patients capacity at the
  time of making the treatment plan or whether it
  applies in the present circumstances, you should
  make the decision based on the patients best
  interests. In making such a decision, you should
  consult with any person with legal authority to
  make decisions on behalf of the patient and the
  patients family if possible.

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What?

• Values and beliefs
• Health care decision, including requests for
  treatment, refusal of treatment
• Preferred place of care
• nominee for consultation

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Who?

• Patient
• Healthcare team-doctor, nurses, social workers
• Family

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When?

• Diagnosis of an illness in which there is likely
  to be loss of capacity
• Diagnosis of an illness, when there are likely to
  be complications needing urgent treatment for
  example respiratory failure in MND,
  cardiopulmonary arrest
• Disease progression indicators
• Hospital admissions

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Where?

• Ideally in usual place of care, with usual
  supports

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Why?

• To respect patients wishes
• To improve end of life care
• To provide clarity for professionals and carers
• To reduce health care costs

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Why not?

• Consistency of wishes
• Undermine doctor-patient trust
• Institutional agenda-cost
• Coping mechanism of patients

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Consistency of wishes

• Patients were more likely to accept treatment
  resulting in certain diminished states of health,
  including pain, as time progressed and health
  deteriorated.
• (Fried et al. Prospective Study of Health
  Status Preferences and Changes in Preferences
  Over Time in Older Adults. ArchIntMed, 166,
  890-5, 2006)

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Consistency of wishes

• Conflicting studies, but raise the question of
  when advance care plans be reviewed

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Undermine Staff-Patient Trust

• Fear of over-aggressive treatment
• Fear of medical paternalism
• Duty of doctor to act in the patients best
  interests

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Institutional agenda

• Cost containment-
• frequent emphasis on withholding and
  withdrawing treatment with the intention to
  reduce costs

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Patients coping mechanisms

• Avoidance
• Denial
• (

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Advance planning considerations

• Autonomy
• Functional capacity
• Informed decision
• Not obligatory
• Cannot oblige futile or unethical or illegal
  treatment

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Advance planning considerations

• Rarely urgent-a process over a number of
  encounters
• Fit for purpose-not so vague as to be useless
• Documented in such a way as to be available when
  needed
• Encourage engagement with family

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Statement of values and beliefs
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Specific statements about treatment refused

• An advance decision to refuse treatment

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Specific statements about treatment requested

• Can be requested, but not enforced

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Specific statements about treatment requested

• Can be requested, but not enforced
• Futile treatment

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Specific statements about treatment requested

• Can be requested, but not enforced
• Futile treatment
• Respect for autonomy of others

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Specific statements about treatment requested

• Can be requested, but not enforced
• Futile treatment
• Respect for autonomy of others
• Fair use of resources

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Advance Care Planning

• Part of current care planning
• At patients request and pace
• If patient does not have capacity, with those who
  understands patients wishes
• In patients best interest
• Document.