Advanced care planning: policy and real-life decision-making?

Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness

This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.

Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model

BACKGROUND

Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders' vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations.

AIM

To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development.

DESIGN

A structured integrative review of relevant literature.

DATA SOURCES

CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018.

RESULTS

From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality.

CONCLUSION

Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.

End-of-life planning with frail patients attending general practice: an exploratory prospective cross-sectional study

Background

End-of-life planning means decision making with patients, formulating and recording decisions regarding their end-of-life care. Although clearly linked with benefits including improved quality of life, reduced hospital admissions, and less aggressive medical care, it is still infrequently undertaken and is regarded as challenging by healthcare professionals.

Aim

To ascertain the feasibility of improving the identification of patients at high risk of dying in general practice and the acceptability of providing patients identified with an end-of-life planning tool.

Design and setting

Exploratory prospective cross-sectional study in four general practices.

Method

Patients at high risk of dying were identified during routine consulting by their GP, using the Supportive and Palliative Care Indicators Tool (SPICT). Patients identified were invited to participate, and provided with Think Ahead — an end-of-life planning tool, which has been used previously in general practice. Participants completed telephone surveys, assessing their response to Think Ahead, and the acceptability of the GP raising end-of-life issues during routine consulting.

Results

Provision of Think Ahead to a purposive sample of preterminal patients identified by GPs was feasible, acceptable to most patients, and somewhat effective in increasing discussion among families and in practice on end-of-life planning.

Conclusion

The SPICT and Think Ahead tools were mostly acceptable, effective, and enabling of discussions on end-of-life care in general practice.