Advance Care Planning
Regina Mc Quillan
Advance care planning
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What?
Who?
Why?
When?
Where?
Medical Council Guidelines
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
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
Paragraph 41.3
If there is doubt about the existence of an
advance care plan, the patient’s 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 patient’s 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
patient’s family if possible.
What?
• Values and beliefs
• Health care decision, including requests for
treatment, refusal of treatment
• Preferred place of care
• ‘nominee’ for consultation
Who?
• Patient
• Healthcare team-doctor, nurses, social
workers
• Family
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
Where?
Ideally in usual place of care, with usual
supports
Why?
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To respect patient’s wishes
To improve end of life care
To provide clarity for professionals and carers
To reduce health care costs
Why not?
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Consistency of wishes
Undermine doctor-patient trust
Institutional agenda-cost
Coping mechanism of patients
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)
Consistency of wishes
Conflicting studies, but raise the question of
when advance care plans be reviewed
Undermine Staff-Patient Trust
• Fear of over-aggressive treatment
• Fear of medical paternalism
• Duty of doctor to act in the patient’s best
interests
Institutional agenda
Cost containmentfrequent emphasis on withholding and
withdrawing treatment with the intention
to reduce costs
Patients’ coping mechanisms
• Avoidance
• Denial
(
Advance planning considerations
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Autonomy
Functional capacity
Informed decision
Not obligatory
Cannot oblige futile or unethical or illegal
treatment
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
Statement of values and beliefs
Specific statements about
treatment refused
• An advance decision to refuse treatment
Specific statements about
treatment requested
• Can be requested, but not enforced
Specific statements about
treatment requested
• Can be requested, but not enforced
• Futile treatment
Specific statements about
treatment requested
• Can be requested, but not enforced
• Futile treatment
• Respect for autonomy of others
Specific statements about
treatment requested
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Can be requested, but not enforced
Futile treatment
Respect for autonomy of others
Fair use of resources
Advance Care Planning
• Part of current care planning
• At patient’s request and pace
• If patient does not have capacity, with those
who understands patient’s wishes
• In patient’s best interest
• Document.