End of Life Care:
Advance Care Planning
Ground Rules
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Confidentiality
Shared learning
One at a time
Respect one another’s opinions
Positive critique
Sensitivity
Time-out
Mobile phones/pagers off please
Any more?........
Learning Outcomes
By the end of the programme the
practitioner will be able to:
• Develop their knowledge and understanding of
the concepts of Advance Care Planning and the
Liverpool Care Pathway and their application to
practice
Advance Care Planning
Advance Care Planning (ACP)
• What do you understand by the term
advance care planning?
• What is the difference between advance
care planning and care planning?
• How many of you have been involved in
Advance Care Planning?
End of Life Strategy (2008)
“All people approaching the end of life need
to have their needs assessed and their
wishes and preferences discussed.”
Advance Care Planning
• A process of discussion between the individual and
their care providers, irrespective of discipline.
• Family/carers may be included if the individual
wishes.
• It is a voluntary process.
• It is recommended that with the individual’s
agreement this discussion is documented, regularly
reviewed, and communicated to key persons
involved in their care.
• County-wide ACP Document – ‘Planning for Your
Future Care’
• The document is held by the individual
• The discussion may include the individual’s
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Concern’s and wishes
Values and goals of care
Understanding of their illness and prognosis
Preferences for care or treatment that may be
beneficial in the future and the availability of
these
• And usually takes place in anticipation of a
deterioration in a person’s condition in the
future where they are not able to make
decisions and/or communicate their wishes
Why is ACP different to other
planning
ACP is undertaken in the context of an
anticipated deterioration in the individual’s
condition with the attendant loss of
capacity to make or communicate
decisions
Killick et al.(2010)
Relevant Documents
http://www.endoflifecareforadults.nhs.uk/eolc/acp.htm
Activity
Split into 4 groups and take 15 minutes to
discuss the following:
1.In what situations in your practice may an
individual wish to consider ACP?
2.What considerations need to be taken into
account when initiating a ACP discussion?
3.What are the benefits and challenges that
ACP presents
Situations in which an individual
may want to consider ACP
• Life changing event – death of spouse
• Following a life threatening diagnosis
• Deterioration or significant shift in
treatment focus
• During assessment of individuals needs
• Following multiple hospital admissions
• In case the unexpected happens
• Future planning
Considerations that need to be
taken into account when initiating an
ACP discussion
• Voluntary
• Respect that the client may not wish to confront
future issues
• Client Centred Dialogue
• ? Family/ carer involvement in discussion.
• Who is the most appropriate to carry out this
discussion?
• Be prepared
P- prepare for the discussion
R- relate to the person
E- elicit pt and carer preferences
P- provide information
A- acknowledge emotions and concerns
R- realistic hope
E- encourage questions
D- document
• Know our own limitations and who to
go to for advice or refer on
• Appropriate communication skills
• Knowledge of support, services and
choices available in the particular
circumstances.
• The professional must have adequate
knowledge of the benefits, harms and
risks associated with treatment for client
to make informed choice.
• Choice of place of care and how that may
influence treatment options
• Client has the Capacity to understand,
discuss options available and agree to
what is then planned
What are the benefits and
challenges?
Client centred approach
Choices
Empowerment
Communication
Confidence
Documentation
Hope
National End of Life Programme
Terms used within ACP
What do you understand by the following
terms?
• Advance Statement
• Advance Decision
• Lasting Power of Attorney
Advance Statement
• Not legally binding
• A written record
• Reflects individual’s aspirations and
preferences or general beliefs and aspects
of life they value
• Helps staff in identifying how clients wish
to be cared
• Can help if there is a need to act in the
‘best interest’ of the client
Advance Decision
• Used to be called Advance Directive /
Living Will
• An advance decision must relate to a
specific treatment and specific
circumstances
• Legally binding if valid and applicable to
the circumstances
• It only comes into effect when the
individual has lost the capacity to give or
refuse consent.
Advance Decisions to Refuse Treatment
‘a decision you can make to refuse a
specific medical treatment in whatever
circumstances you specify’
• Over age 18yr, has mental capacity
• Written or verbal
• Must be written/signed and witnessed if it includes a
refusal of life sustaining treatment
• Should be guided by a professional with appropriate
knowledge
• Only becomes active when patient loses capacity
• Applies only to a refusal of a treatment
It is not valid …..
• If it is withdrawn by the individual who made
it
• A Lasting Power of Attorney has been
created subsequent to the advance decision
• The individual has done anything that is
inconsistent with the advance decision.
• Does not apply to the specifically stated
circumstances
• (Consideration may be given to long lapses
of time during which medical treatment
advances have been made.)
Relevant Documentation
http://www.endoflifecareforadults.nhs.uk/eolc/acpadrt.htmlevant
Advance Care Planning and the
Mental Capacity Act (2005)
Advance Care Plans must meet the
requirements of the Mental Capacity Act
(MCA).
• Assumed to have capacity
• Supported to make own decisions, even if
it is unwise
• Best interests
• Least restrictive of their rights and freedom
Lasting Power of Attorney (LPA)
LPA’s can
• Cover health and welfare decisions
• Be registered at any time and MUST be
registered before they are used
• Attorney’s acting under LPA act in
accordance with the principles of Mental
Capacity Code of Practice.
The Law Society (2010)
References
Department of Health (2008) End of Life Care Strategy. London: DH
Department of Health (2010) End of Life Care for All (e-ELCA),
accessed on 01/12/2010 http://www.e-lfh.org.uk/projects/eelca/index.html
Henry, C. & Seymour (2008) Advance Care Planning: A guide for health
and social care staff, Department of Health, accessed on 31/08/2010
http://www.ncpc.org.uk/download/publications/AdvanceCarePlanning.pdf
Killick, S., Pharaoh, A. & Randall, F. (2010) Advance care planning in
care homes, Palliative Medicine, Vol 24, No 4, pp. 445-446.
The Law Society (2010) Assessment of Mental Capacity, Capacity to
consent to and refuse medical treatment and procedures., Chapter
13, 3rd edition pp. 130-131.
NHS Gloucestershire (2010) Planning for Your Future Care, Advance
Care Planning.
Resources
• Advanced Care Planning- www.endoflifecare.nhs.uk
• Advance Decisions to Refuse Treatment- A guide for
Health and Social Care Professionalswww.endoflifecareforadults.nhs.uk
• Good Decision Making-The Mental Capacity Act and
End of Life Care- www.ncpc.org.uk
• National End of Life Care Strategywww.dh.gov.uk/publications
• Planning for your Future-A Guide- www.ncpc.org.uk
• Preferred Priorities for Care-www.endoflifecare.nhs.uk
• Any questions?