An unequivocal good? acknowledging the complexities of advance care planning (original) (raw)
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Internal Medicine Journal, 2007
The AMA has recently adopted a policy position concerning advance care planning, which is generally supportive of extending patient self-determination beyond the loss of decision-making capacity. It calls for uniform national legislation for legally enforceable advance health directives (AHDs), and statutory protection for practitioners who comply with valid AHDs, or who do not comply on a number of grounds. Analysis of the grounds for non-compliance indicate that they undermine patient autonomy, and aspects of the policy are inconsistent with current common law and statutory regimes that allow an adult to complete a legally binding AHD. The policy therefore threatens the patient self-determination which it endorses, and places doctors who participate in advance care planning at legal risk.
BMC health services research, 2017
Advance care planning (ACP) is a process of planning for future health and personal care. A person's values and preferences are made known so that they can guide decision making at a future time when that person cannot make or communicate his or her decisions. This is particularly relevant for people with dementia because their ability to make decisions progressively deteriorates over time. This study aims to evaluate the cost-effectiveness of delivering a nationwide ACP program within the Australian primary care setting. A decision analytic model was developed to identify the costs and outcomes of an ACP program for people aged 65+ years who were at risk of developing dementia. Inputs for the model was sourced and estimated from the literature. The reliability of the results was thoroughly tested in sensitivity analyses. The results showed that, compared to usual care, a nationwide ACP program for people aged 65+ years who were at risk of dementia would be cost-effective. Howev...
Australian Journal of …, 2012
This article presents findings from six focus groups with health care practitioners in an Australian hospital during 2010, which sought to elicit their perspectives on the barriers for people to plan their future health care should they become unwell. Such knowledge is invaluable in overcoming the barriers associated with advance care planning and enhancing the uptake of advance directives and the appointment of an enduring power of attorney for people of all ages. A person's rights to self-determination in health care, including decision making about their wishes for future care in the event they lose cognitive capacity, should not be overlooked against the backdrop of increasing pressure on health care systems. Findings suggest that multiple barriers exist, from practitioners' perspectives, which can be divided into three major categories, namely: patient-centred, practitioner-centred and system-centred barriers. Specifically, patient-centred barriers include lack of knowledge, accessibility concerns, the small 'window of opportunity' to discuss advance care planning, emotional reactions and avoidance when considering one's mortality, and demographic influences. At the practitioner level, barriers relate to a lack of knowledge and uncertainty around advance care planning processes. Systemically, legislative barriers (including a lack of a central registry and conflicting state legislation), procedural issues (particularly in relation to assessing cognitive capacity and making decisions ad hoc) and questions about delegation, roles and responsibilities further compound the barriers to advance care planning.
Advance care planning: Let's start sooner
PubMed, 2015
dvance care planning (ACP) is a communication process wherein people plan for a time when they cannot make decisions for themselves. It includes reflection, deliberation, and determination of a person's values and wishes or preferences for treatments at the end of life. Advance care planning should also include communication between an individual and his or her loved ones, future substitute decision makers (SDMs), and health care providers about these values and wishes. Evidence supports the effectiveness of ACP to improve the end-of-life experiences of patients and families. 1,2 Despite the known benefits of ACP, 3 often people with life-limiting illnesses facing an acute health crisis have not spoken up about their preferences. 4 It is estimated that approximately half of Canadian adults have engaged in some type of end-of-life discussion with family members or friends. 5 However, it is much less common for people to communicate their preferences to health care providers. In one Canadian survey, only 9% of respondents had discussed their preferences with health care providers. 5 Research on the extent of engagement in ACP in Canadian health care settings has been done largely from the acute care perspective. One study reported that the documented medical orders for life-sustaining treatments in Canadian hospitals reflected the expressed preferences of patients only one-third of the time. 4 This finding is surprising, as a study about family practices in Canada found that nearly all patients were familiar with the term do not resuscitate, 86% were interested in discussing wishes with their family physicians, and most wanted to have the discussion while they were healthy. 6 Clearly there is a communication gap between patients and health care providers.
Developing a Legal Framework for Advance Healthcare Planning: Comparing England & Wales and Ireland
This article explore the choices made in two Council of Europe member states with common law traditions, both of which have relatively recently introduced legislative frameworks for advance healthcare planning. In England and Wales, the relevant measure is the Mental Capacity Act 2005 (MCA) which came into effect on 1 October 2007 while, in Ireland, the legislation is the Assisted Decision-Making (Capacity) Act 2015 (ADMA), which was signed in law on 30 December 2015 and is expected to come into effect in 2017. Notwithstanding a number of similarities between the MCA and the ADMA, some interesting variations may be identified, reflecting differences in approach to the underlying principles of autonomy and protection. This article undertakes a comparative exploration of each measure, both in terms of background and also in terms of the detail of the approaches taken.
Rural and Remote Health, 2018
Introduction: Advance care planning (ACP) and advance care directives (ACDs) play a vital role in preparing for end-of-life care. However, current literature suggests that uptake of ACP and ACDs in rural Australia is low, which may contribute to lower quality care for the older rural population, as patients' end-of-life wishes may not be recognised and acknowledged. This study aims to provide a current perspective on the attitudes and practices of healthcare workers from residential aged care facilities towards ACP and ACDs in the central west, far west and Orana regions of New South Wales, Australia. Methods: This was a mixed-methods study incorporating anonymous survey and individual interviews. Healthcare workers from 12 residential aged care facilities within the studied region completed surveys (n=109). The 40-item survey assessed participant demographics, training and experience with ACP and ACD, attitudes towards ACP and ACDs, and barriers and facilitators towards the use of ACP and ACDs in their organisation. Five participants were interviewed to explore these issues in more depth. Results: Almost three-quarters (71%) of respondents thought that ACP is necessary while almost half (48%) were involved with >5 ACDs in the past 12 months. Formal training was seen as beneficial by most (81%) but the importance of practical experience was also acknowledged. No statistically significant differences were found in attitudes between those with <5 years and those with >5 years of experience. Avoidance of unnecessary resuscitation was a consistent theme in all interviews and the potential of a nurse-led model of delivery was identified. Patient factors such as decreased capacity to make informed decisions were identified as barriers that could be circumvented by pre-emptive implementation of ACP discussion. The rural setting was identified as a facilitator due to a supportive community, which helped to mitigate barriers such as limited staffing. Conclusions: Attitudes towards ACP in rural New South Wales are highly positive. The rural setting is a facilitator to ACP, and ACDs are approached in a multidisciplinary fashion. Further training is an identified need although on-the-ground experience may be more beneficial.
2017
Advance care planning (ACP) has become an integral part of patient care because of its ability to help guide treatment decision making for individuals in need of medical care but who have lost the ability to communicate— temporarily or permanently—due to illness or injury. Not all persons have the same treatment threshold; some persons value their lives above all else and will accept a high level of physical debility regardless of personal discomfort to stay alive. Others value their individual personal comfort over the length of their lives and will refuse otherwise life-sustaining treatment if they believe the treatment will cause them to sacrifice their comfort. The purpose of ACP is to help mentally capable adults express their individual goals, values, and treatment preferences prior to becoming unable to communicate so that medical providers and loved ones can make treatment decisions that best align with those adults’ wishes. When persons in need of medical care have not done...
Advance care planning in New Zealand: A qualitative study of the motivators and barriers to uptake
Australasian Journal on Ageing, 2020
ObjectiveAs a follow‐up to the first national survey of advance care planning uptake in New Zealand, which demonstrated a low level of plan completion, this study seeks to better understand the motivators and barriers associated with uptake.MethodsUsing a qualitative approach and a purposeful sampling method, nine interviewees participated in semi‐structured interviews exploring in further depth their knowledge, attitudes and activities in relation to planning for end‐of‐life care. Thematic analysis was applied to the transcripts and several key themes identified.ResultsThe five key themes were Knowledge of Advance Care Planning; Incomplete Planning; Relational Autonomy; Focus on Family; and Still Time to Plan.ConclusionA stepped process to encourage planning uptake is suggested, with legal and financial steps preceding the making of more personal values–based decisions salient to a serious diagnosis.
Adversaries at the Bedside: Advance Care Plans and Future Welfare
Advance care planning refers to the process of determining how one wants to be cared for in the event that one is no longer competent to make one's own medical decisions. Some have argued that advance care plans often fail to be normatively binding on caretakers because those plans do not reflect the interests of patients once they enter an incompetent state. In this article, we argue that when the core medical ethical principles of respect for patient autonomy, honest and adequate disclosure of information , institutional transparency, and concern for patient welfare are upheld, a policy that would allow for the disregard of advance care plans is self-defeating. This is because when the four principles are upheld, a patient's willingness to undergo treatment depends critically on the willingness of her caretakers to honor the wishes she has outlined in her advance care plan. A patient who fears that her caretakers will not honor her wishes may choose to avoid medical care so as to limit the influence of her caretakers in the future, which may lead to worse medical outcomes than if she had undergone care. In order to avoid worse medical outcomes and uphold the four core principles, caregivers who are concerned about the future welfare of their patients should focus on improving advance care planning and commit to honoring their patients' advance care plans.