Transcript Advanced Care Planning

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
UNIVERSITY
CLARIFICATION OF THE TERM:
ADVANCE 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
UNIVERSITY
CLARIFICATION OF THE TERM:
ADVANCE CARE DIRECTIVE
• Also referred to as an advance care plan
• A written or oral expression of the person’s 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
UNIVERSITY
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
Lakehead
UUNNI IVVEERRSSI ITTYY
BENEFITS TO EFFECTIVE ADVANCE CARE PLANNING
• Person’s 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
UNIVERSITY
CAPACITY
A central issue in advance care planning
• Adults are presumed capable unless proven
•
otherwise
• Common law test for capacity:
• Person’s ability to understand the relevant
information
• Person’s 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:
•
•
•
•
•
Capacity Assessment Outcomes
(Capacity to Consent)
Full/Complete
Partial Capacity
Total Capacity
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
Lakehead
UNIVERSITY
POWER OF ATTORNEY FOR PERSONAL CARE
SELECT
INDIVIDUAL 16
years or older TO
ACT AS YOUR
POA
•
WRITE
INSTRUCTIONS
& SIGN/DATE
DOCUMENT
SIGNATURE OF
TWO
WITNESSES
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
UNIVERSITY
SUBSTITUE DECISION-MAKER
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
Hierarchical List under Provincial
Legislation to be used if a POA has not
designated an individual:
Your spouse, common-law spouse or
partner
Your child (if they are 16 years of age or older)
or parent
• know you well
• be someone you trust
• be able to make decisions under
stress
Your parent with right of access only
Custodial parents rank ahead of noncustodial parents
Your brother or sister
Any other relative by blood, marriage or
adoption
The Office of the Public Guardian and
Trustee - last resort
Lakehead
UNIVERSITY
http://www.attorneygeneral.jus.gov.on.ca/english/family/pgt/poa.pdf
COMMUNICATION
Points for Health Care Providers to Consider When Discussing ACP
 Review, recognize and reflect on personal views of ACP
Avoid
Medical
Jargon
 Direct conversations to the older person
Be
Clear
&
Direct
 Recognize the amount of details a person wants
will vary with the individual
 Acknowledge cultural diversity
Allow Time
for
Reflection
 Do not assume that communication difficulties
equate to not understanding or not having anything
to say
 ASK for help; bring in appropriate assistance
when necessary (other team members; interpreters;
communication devices)
Lakehead
UNIVERSITY
Don’t
assume you
understand
ASK
STATEMENTS TO GET THE CONVERSATION STARTED
We ask everybody if they have a living will or
power of attorney for personal care. Do you have
these?
Can you identify a person who you would trust to
make health care choices for you if you became
unable to do this yourself?
We like to discuss with each person what they
want for end-of-life care so we can honour their
wishes. Can we talk about this now?
Ask about values and goals: what makes life worth
living now? What do you hope for now and in your
future? What would make life not worth living?
Lakehead
UNIVERSITY
QUESTIONS TO ANSWER IN ADVANCE CARE PLANNING
Have you given the person relevant information in language appropriate to
their level of understanding and in their language of fluency?
• When should attention turn to providing comfort rather than
continuing to fight the disease or illness?
What kinds of measures or treatments should be considered? Are there
any medical treatments which the person fears or does not want?
• Have you given the person all the available choices and information on
what each alternative involves – risks and benefits?
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 person’s
previously expressed values and beliefs.
Lakehead
UNIVERSITY
ADVANCE CARE PLANNING GUIDE
GET THE
INFORMATION
YOU NEED
DICUSS ANY
THOUGHTS,
CONERNS, AND
CHOICES
Make A Plan
• Consult people you trust: e.g. family and friends; healthcare providers; lawyer; spiritual advisor
• Access media information via web sites, books, videos etc.
• http://www.attorneygeneral.jus.gov.on.ca/english/family/pgt/poa.pdf
• Medical treatments, nutrition, hygiene, living arrangements, personal safety issues
• Revisit the discussion, especially whenever changes in medical status occur
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•
•
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Decide on a substitute decision-maker – talk about POA
Discuss and decide what is needed in your personal ACP
Write down your AD
Have copies available for your POA/SDM, family or friends to provide to health care agencies
Lakehead
UNIVERSITY
HAVE YOU COMPLETED YOUR PLAN?
“ PLANNING IS BRINING THE
FUTURE INTO THE PRESENT SO
THAT YOU CAN DO
SOMETHING ABOUT IT NOW”
Alan Lakein
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/programs/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/family/pgt/poa.pdf.