Advance Care Planning: ACP in 3-Steps. Dr Barbara Hayes Palliative Care Physician Clinical Leader Northern Health ACP Program.

Transcription

1 Advance Care Planning: ACP in 3-Steps Dr Barbara Hayes Palliative Care Physician Clinical Leader Northern Health ACP Program Traralgon 2016

2 Advance Care Planning Informing Consent Advance Care Planning in 3-steps Advance Care Planning as part of usual practice

3 ACP ACP in 3-Steps in 3-Steps Northern Northern Health 2009Health 2009

4 Advance Care Planning is a process of planning for future health care decisions - in advance Plan only comes into effect if and when a person is unable to make decisions for themself

5 Advance Care Planning is a process of planning for future health care, where a person s values, beliefs and preferences are made known, so they can guide clinical decision making, at a future time when that person cannot make or communicate their decisions due to lack of capacity.

6 ACP informs the in-the-moment future decisions required at a time of deterioration Rather than making medical treatment decisions now, for a future hypothetical deterioration (Sudore & Fried. Annals of Internal Medicine. 2010)

7 Medical decision-making based on - (i) A medical assessment & a medical decision about treatment and what is clinically feasible then within those constraints (ii) A shared decision-making discussion between clinician and patient and/or substitute decision-maker leading to An agreed medical treatment plan: - Overall medical treatment goals & - Specific emergency medical treatments / limitations

8 Medical decision-making based on - (i) A medical assessment & a medical decision about treatment and what is clinically feasible then within those constraints (ii) A shared decision-making discussion between clinician and patient and/or substitute decision-maker leading to Taking into account prior ACP An agreed medical treatment plan: - Overall medical treatment goals & - Specific emergency medical treatments / limitations

9 Medical decision-making based on - (i) A medical assessment & a medical decision about treatment and what is clinically feasible then within those constraints (ii) A shared decision-making discussion between clinician and patient and/or substitute decision-maker leading to An agreed medical treatment plan: - Overall medical treatment goals & - Specific emergency medical treatments / limitations CPR / NFR decision

10 Two experts in shared decision-making The doctor and treating team are the experts in the medicine They interpret the medicine within the patient s context + = The Patient their Person Responsible and the broader family are the experts on the patient They interpret who the patient isand what is important to them. Together they come to a shared understanding about what would be in the best interests of the patient Consent

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14 Advance Care Planning in 3-steps A C P Appoint an Agent Chat & Communicate Put it on Paper

15 Advance Care Planning in 3-steps A Appoint an Agent Appoint an Agent Remember, the competent patient can: Consent to, or refuse, treatment for themself Appoint a Substitute Decision Maker: Chat and Communicate Medical Enduring Power of Attorney to consent to or refuse treatment Person Responsible in writing to consent to treatment Put it on Paper

16 Advance Care Planning in 3-steps Chat & Communicate Appoint an Agent Encourage and facilitate patients to speak with families / friends to talk about: C Things I value are. Chat and Communicate Future situations that I would find too burdensome/distressing in relation to my health are. Specific treatments that I would NOT want considered for me are. ( and WHY?) Put it on Paper This is who I would like to be involved in decisions.

17 Advance Care Planning in 3-steps Put it on Paper Appoint an Agent Advise your patient that if there is something they feel strongly about they can write it down and give a copy of their documents to the relevant people. Advance Care Planning instructional documents can include: Chat and Communicate P Refusal of Treatment Certificate Non-legislated Advance Care Plan Put it on Paper

18 Put it on Paper Patients should consider Instructional Advance Care Plan / Directive Strong preferences re future healthcare Socially isolated Different views re medical treatment in family

19 When is it a good time for ACP?

20 Cues First contact ask if patient has MEPOA or ACP Patient who raises concerns about future After an acute exacerbation or period of deterioration 75+ assessment or chronic disease planning Patient with strong preferences Patient with no-one Patient with complex family structure / situation

21 What to say All approaches to ACP can be variations on: Who would make medical decisions for you if you were too ill to do this for yourself and how would they know what you would want?

22 If for some A. reason down the track you were unable to talk to us The Agent yourself, who would you like us to talk with? Is this the person who you would wish to be responsible for helping the doctors to make your medical decisions or is there someone else that would be better suited for that role? You seem to have a very large family - who would be the best person for us to talk with about medical details if we needed to?

23 Have you thought about what things you would want them to know in order to make the best decisions on your behalf? C. The Communication Sometimes the decisions that the person needs to make can be quite difficult. Knowing how you would think about these things can help them in making these decisions. Have you already spoken to them about this? What sorts of things have you already discussed together?

24 You can write down some of the things you feel very strongly about P. The Paperwork I noticed that you and your children have different views on what should happen; writing down your preferences can help make it clear what you would want. Sometimes it can help your family and the doctors to remember your preferences if they are recorded

25 But listen first Get the story and the patient s (Person Responsible s) concerns Think about where ACP might help address concerns - rather than just another task

26 ? It sounds like the last few weeks have been really difficult? How are you coping?? What are you most worried about?? What is the worst thing for you at the moment?? What are you most hoping for? If that doesn t work out the way you are hoping, what else would you be hoping for?

27 Recognise when you have done ACP Record it and make the information accessible for the next person The 2:00am test!!

28 Activating Advance Care Planning The Paperwork Appoint an Agent Ask if the patient has completed written ACP documents and ask to see them P Advance Care Planning documents can include: Appointment of a Substitute Decision-Maker Chat and Communicate Instructional Advance Care Plan /Directive: Statutory Non-statutory Put it on Paper Consider if: Intentions are clear Instructions are still current Apply to current situation Freely written Oral communications are also valid

29 Palliative Care The OLD The NEW

30 Palliative Care The OLD The NEW Palliative Care Life prolonging therapy End-of-life care Incurable illness Death

31 Palliative Care The OLD The NEW Terminal or dying Treatment of Underlying disease Other life-prolonging Medical treatment Symptom management & supportive care Incurable illness Death Bereavement support

32 A C Appoint an Agent Chat & Communicate P Put it on Paper Dr Barbara Hayes Clinical Leader Advance Care Planning Northern Health Barbara.Hayes@nh.org.au Northern Health Advance Care Planning Program Vic Department of Health and Human Services Office of the Public Advocate

33 References Sudore R & Fried T. Redefining the Planning in Advance Care Planning: Preparing for end-of-life decision making. Annals of Internal Medicine (4):