Insights into Advance Care Planning in Africa

Advance Care Planning is an important element of palliative care whose relevance has over the years shifted from focusing on patients at end of life to being applicable at any stage of an individual's health. It is said to be beneficial not only to the patient but also to the general health care system. It may facilitate a peaceful death in addition to minimizing unnecessary costs and the use of resources yet its use among health care workers in Africa is not well researched. This study therefore aimed to explore the use of Advance Care Planning among health care providers in sub-Saharan Africa. It was a survey that targeted health care professionals across Sub-Saharan Africa who were either current staff or alumni of Hospice Africa Uganda (HAU) between 2012 and 2023. These were conveniently sampled from HAU data base. An electronic survey was sent out, data was collected into an excel sheet and it was analysed descriptively. Responses to the survey came from nine out of 37 countries with PC services across Africa and there was a 14% response rate. 83% of the respondents had insight into Advance Care Planning and a surprise finding was that 40% had cared for patients with ACP. The majority (96%) would respect Advance Care Plans of their patients. These findings gave some insights into the use of ACP although the results cannot be generalised to a wider demography of healthcare providers.

Advance Care Planning in Spain

In the last decade in Spain, an important push has been given to the development of health policies that define the framework of action in the care of people with advanced chronic diseases. Respect for the autonomy of the patient, shared decision-making processes and advance care planning (ACP) are recognized into health plans as a key aspect in chronic care, frailty, and palliative care. A few but significant number of institutions, local governments, and healthcare professionals from different regions of Spain have started a rationale and roadmap for a new twist in Spain's theoretical, ethical and policy development, promoting ACP implementation into public health care systems. In 2020, a working group founded in 2017, evolved into the "Spanish Association of Shared Care Planning" (AEPCA). The Shared Care Planning (SCP) concept grows up after the two international consensus Delphi studies in 2017 and pretends to shift from the framework of ACP programs to a person-centred care approach. In the last years, several experiences show how professionals are more sensible and interested on the ACP process, but it cannot be said, for now, that it has taken effect in the global Spanish health system. Even both ACP and SCP are being used simultaneously in Spain, each day more people and autonomous communities embrace renewed concept and foundations of SCP, supporting the work of AEPCA on spreading the value of this process into the care of people who are coping with chronic diseases, vulnerability, and frailty.

Advance Care Planning in South Korea

South Korea is an Asian country with a very low birth rate and a large elderly population. Nearly half of deaths are in the elderly over the age of 80, and cancer is the leading cause of all deaths. As the aging population increases, interest in end-of-life (EOL) care and quality of death is growing, but South Korea is one of the Asian countries that traditionally feels burdened by discussing death openly. In particular, even when a person is suffering from an incurable disease and is about to die, it is customary for the family members to make decisions without directly informing the patient of the disease status or discussing life-sustaining treatment (LST). However, due to a series of social events, the importance of individual autonomy, good death, discontinuation of LSTs, and advance care planning (ACP) gradually spread, and eventually the Life-Sustaining Treatment Decisions Act was implemented in 2018. With the enactment of this law, patients' autonomy was enhanced in a short period of time, and a legal basis was established to discontinue LST at the EOL. However, there are still many areas to be improved, and it is fundamentally necessary to spread the concept of 'ACP' within society.

Advance Care Planning in the United States: A 2023 review

Advance Care Planning (ACP) in the US is complex due in part to a lack of a unified health care system, though more recent policy changes permitting reimbursement for ACP conversations offer some hope. One key barrier to ACP is public perceptions of ACP, made worse by a historical focus on messaging that is unappealing and does not meet people's need to focus on the present before contemplating the future. As we learn more about how to engage the public, there is also increasing recognition that the previous focus on making very specific decisions about the future needs to shift to a focus on preparing people for communication and decision making. Numerous programs exist for health care professionals to support meaningful explorations of goals, values, and preferences, and there is growing availability of resources to support this work, both in the community and health care setting. Further research is needed to understand the full complexity of ACP implementation and to identify person-centred outcomes to support high quality ACP.

Making Advance Care Planning a part of cancer patients' end-of-life care in Rwanda

After the devastating damage inflicted by the 1994 Genocide against the Tutsi, Rwanda made great strides in reconstructing its healthcare system from scratch. Although cancer mortality rates continue to rise, there is still a dearth of qualified healthcare workers for advance care planning (ACP) for terminally ill patients. I will draw on lessons learned through the literature search for the initiation of ACP and reflect on their adaptation to the existing policies, healthcare systems, and workforce in Rwanda. We hope to introduce advance care planning into the clinical package given to patients with cancers in terminal illness and their families in Rwanda. The introduction of ACP by skilled, qualified, and specialized healthcare professionals in Rwanda will help establish a practical ACP strategy at the hospital and in the community to benefit patients and their loved ones for an enhanced quality of life in end-of-life care. There is a need for training, policy-making, and community mobilization for the awareness of ACP.

Advance Care Planning in the Netherlands

The Dutch health care system fosters a strong public health sector offering accessible generalist care including generalist palliative care. General practitioners are well positioned to conduct ACP, for example, to continue or initiate conversations after hospitalization. However, research shows that ACP conversations are often ad hoc and in frail patients, ACP is often only initiated when admitted to a nursing home by elderly care physicians who are on the staff. Tools that raise awareness of triggers to initiate ACP, screening tools, information brochures, checklists and training have been developed and implemented with funding by national programs which currently focus on implementation projects rather than or in addition to, research. The programs commonly require educational deliverables, patient and public involvement and addressing diversity in patient groups. A major challenge is how to implement ACP systematically and continuously across sectors and disciplines in a way that supports a proactive yet person-centered approach rather than an approach with an exclusive focus on medical procedures. Digital solutions can support continuity of care and communication about care plans. Solutions should fit a culture that prefers trust-based, informal deliberative approaches. This may be supported by involving disciplines other than medicine, such as nursing and spiritual caregiving, and public health approaches.

Advance Care Planning and palliative care for patients with advanced cancer in Uganda

The study sought to identify the extent to which Advance Care Planning (ACP) is practised by palliative care health professionals providing care to patients with advanced cancer and their families in Uganda. A mixed methods study design using qualitative and quantitative methods was used for the assessment. In-depth interviews with a group of nine highly experienced health professionals were conducted using a semi-structured interview guide. Quantitative data were retrieved and analysed from a survey administered to 124 health professionals of whom only 57 (45.9%) responded. The qualitative data were analysed using inductive thematic analysis and descriptive analysis was used for the quantitative data. Of the 57 health professionals who participated in the survey, 87% were aware of ACP and 55% reported regular practice. Fifty-five (55%) percent reported regular provision of ACP for their patients and 46% reported engaging in informal ACP practices. However, 58.5% resp. 37.5% reported that they routinely provide ACP to more than 50% resp. 75% of their patients. A group of nine highly experienced palliative care professionals had a pooled ACP prevalence of only 1.2%. There was a generally good attitude towards ACP with 98.2% acknowledging that patients should be able to determine their future care. However, 32% reported being uncomfortable withholding or withdrawing life sustaining treatment. There are a number of socio-cultural beliefs and barriers, for instance that discussing death and dying is a "taboo", as well as witchcraft, family influence in decision-making, religious beliefs that do not agree with palliative care practices and a preference to use aggressive treatment like chemotherapy for terminally ill, etc. Institutional barriers like lack of a legal framework for ACP, limited time for health professionals to engage in ACP and other patient factors such as denial of diagnosis and collusion to withhold information from patients were reported by 78.2% resp. 84% of the respondents. Despite the good awareness and attitude to ACP, there is a range of barriers that are affecting the implementation of ACP in Uganda. There is need for development of a legal framework for ACP, more research to understand the contextual barriers and develop appropriate education and public sensitisation programs.

Practices to overcome the inexistence of Advance Care Planning in Poland

Although the first Advance Care Planning (ACP) models were developed decades ago, Poland is still a country where ACP has not yet been implemented, despite its apparent benefits for both patients and the health care system. This article presents the legal and cultural context, main impediments, and opportunities for implementing ACP in Poland. Legal regulations are mandatory to ensure respect for the patient's will. Raising public awareness seems to be a cornerstone of the shift of paradigm. We strongly believe that the support of experienced countries is indispensable.

Advance Care Planning in Ecuador

Advance Care Planning is a process by which a patient's health care preferences are established in advance in the event that he or she become temporarily or constantly unable to make decisions for themselves in the future. It is also applied early in emergencies, in intensive care treatment, and after surgery where one's ability to decide is reduced. In Ecuador there is currently no legislation on this subject, however, the National Health Bioethics Commission validated and published the document "Advance Living Will" and as an important advance issued a favorable criterion before the National Assembly for it to be incorporated into the Organic Health Code, the concept, regulations, and the text of Vital Advance Will. Instead of, its use is currently not in force. However, the compliance criteria have been established in the Palliative Care Standard since 2015, but are not yet implemented. There are few studies that demonstrate its application in the country, so it is important to know the cultural and social characteristics of both health professionals and patients, which limit its application.

Advance Care Planning in Hong Kong

Hong Kong is a well-developed city with outstanding healthcare services, leading to the highest life expectancy in the world. Paradoxically, the quality of end-of-life care in this city lagged behind that of many other high-income regions. Possibly, the advances in medicine contribute to the death denial culture, hindering communication about end-of-life care. This paper discusses challenges arisen due to poor public awareness and professional training and local initiatives to promote advance care planning in the community.

Tō tatou reo - Our voice: Advance Care Planning in Aotearoa New Zealand

The advance care planning programme in Aotearoa New Zealand aims to empower all New Zealanders to participate in planning their future health and end-of-life care. Guided by the core values of our 2022-25 strategy, the programme has developed education, tools and resources to support consumers, their family and whānau and clinicians to optimise the opportunities for what matters most to a person to guide and inform care delivery throughout their life.

Advance Care Planning in Australia: Progress in research and implementation

Advance Care Planning in Australia has its foundations in the Respecting Patient Choices model, which was initially implemented in one state. The Australian population is diverse, ageing and geographically dispersed, with health and aged care services provided by a range of different organisations and regulated at different levels. Key challenges in ACP implementation include discomfort with ACP discussion, inconsistent legislation and ACP documentation across jurisdictions, poor quality control of ACP documents and difficulties accessing ACP documents at the point of care. The COVID-19 pandemic exposed a range of issues but also led to some innovative practices which have continued after the relaxation of public health restrictions. Ongoing implementation work focuses on meeting the needs of diverse communities and sectors in ACP, while seeking an overall coherence in policy and standardisation of practice through high-level best-practice principles, quality standards and policy frameworks.

Advance Care Planning in Belgium

This paper aims to 1) describe current levels of Advance Care Planning (ACP) development since 2002 in Belgium, 2) report on challenges and opportunities to inspire other countries with similar contextual characteristics and 3) support further development of ACP practice and research in Belgium. To address these aims, we consulted local researchers, 12 domain experts and (grey) literature (regulatory documents, reports, policy documents and practice guidelines) on ACP, palliative care, and related healthcare topics. Since 2002, when the Patient's Right Law was passed in the federal Parliament, Belgium has had a specific medicolegal context for ACP. Initiatives to improve the uptake of ACP have been taken, e.g. standardised documentation, reimbursement codes for physicians provided by the government, and implementation of quality indicators in hospitals and nursing homes. Most of these initiatives are grassroots or predominantly oriented towards a single group of professions, e.g. general practitioners, disregarding the role that other professions can play. The patient groups most often targeted are those with cancer and older adults. Limited but growing attention is given to those with low health literacy or other minority groups. Main barriers to ACP in Belgium are: no unified platform to exchange outcomes of ACP discussions or advance directives between healthcare professionals and though efforts are made, ACP is still predominantly oriented towards documentation.

How should Argentina raise Advance Care Planning awareness? Introduction of the Shared Care Planning Group

The WHO Concept Model of Palliative Care emphasises empowering people and communities with Advance Care Planning (ACP). In Latin America, a more relational approach involving family members is suited to ACP. Improvements in doctor-patient-family relationships are needed. Policy efforts have been made to foster ACP in Argentina's healthcare system, but implementation barriers include a need for more communication skills and coordination between healthcare providers. The Shared Care Planning Group Argentina aims to promote ACP through research and training programs. It has sensitised and trained 236 healthcare providers in short courses to introduce basic information and skills. However, there needs to be specific documentation for ACP in Argentina. Research found obstacles to ACP implementation, such as the inability to converse with patients and the lack of coordination between healthcare teams. A new project will assess the self-efficacy of healthcare professionals who assist patients with Sclerosis Lateral Amyotrophic in ACP and evaluate a specific training program. Patient and public involvement in ACP remains limited in Argentina, with paternalistic medical culture and a need for more awareness and training among healthcare professionals as significant barriers. Collaborative research projects with Spain and Ecuador aim to train healthcare professionals and evaluate ACP implementation in other Latin American countries.

Thailand's experience in Advance Care Planning

In 2007, Thailand enacted the National Health Act, which contains the Advance Directive (Section 12). Even though the Act was enacted nearly sixteen years ago, physicians have not fully adopted it, limiting the number of patients who can benefit from the Advance Directive. Thai culture values the role of extended family in end-of-life planning, which is frequently marked by a conspiracy of silence (inability to discuss end-of-life issues), so patients may have limited opportunities to participate in decision-making and care planning. Thailand introduced a Palliative Care Policy in 2014. The inclusion of palliative care in the health service plan is the most crucial factor for palliative care provision. Through health inspections, the Ministry of Public Health supervises, monitors, and evaluates the management of the National Palliative Care Program. Advance Care Planning (ACP) and three other major KPIs were to be included in health inspections by 2020. In 2021, the Office of the National Health Commission implemented ACP, including the formation of (a) a committee to create a national ACP form and standard operating procedures and (b) a steering committee to oversee the nationwide implementation of ACP.

Advance Care Planning in Switzerland: Chances and challenges of delivering high-quality ACP in a small high-income, multilingual, federally organized country

We describe the development of ACP in Switzerland during the last decade in the German- and French-speaking cantons and on the national level. In 2013, a revision of the Swiss civil law came into force, declaring advance directives (ADs) as binding. Since then, ACP has been researched and implemented primarily by universities and university hospitals. Despite the foundation of the national association "ACP Swiss" in 2020, several national initiatives, and a roadmap for a national implementation, many challenges and barriers still remain. There is, however, reasonable hope to implement high-quality ACP throughout Switzerland within the next ten years.

Implementation of Advance Care Planning in Norway

Advance Care Planning has a relatively short history in the Norwegian health care services. This article gives an overview of advance care planning research and its implementation in the health care services in Norway. Advance care planning has received increased attention from policymakers and the health care services. Research projects have been performed, and several are on-going. Implementation has largely treated advance care planning as a complex intervention, with a whole-system approach that puts emphasis on the conversation and patient activation. Advance directives have a peripheral role in this context.

Advance Care Planning in the Philippines: A continuing narrative of advocacy

This article discusses the current state of Advance Care Planning (ACP) in the Philippines, where the health system operates within a fragmented environment, with mixed private and public provisions. Despite some attempts to introduce legislation to foster ACP implementation, patient autonomy remains subordinate to family values and physician authority within the Southeast Asian culture. The article also highlights how the COVID-19 pandemic has challenged the norms of the global healthcare force and pushed Palliative Medicine specialists to take on stronger roles in the battle lines against health-related suffering. The Palliative Care Consultants, advocates along with Philippine Society of Hospice and Palliative Medicine (PSHPM) and Hospice Philippines Inc. have been playing a significant role in promoting and supporting ACP through education and training, advocacy, research and development, networking and collaboration.

Advance Care Planning in South Africa

South Africa (SA), an upper middle-income country, faces significant challenges, including severe inequality, poverty, high unemployment rates, unequal access to basic services, and a long history of human rights violations. It is a diverse nation with eleven official languages. The country also bears a heavy burden of communicable and non-communicable diseases, with many patients seeking healthcare services too late. Despite the pressing need, palliative care is still an emerging field in South Africa, with limited funding allocated for its integration. Advance Care Planning (ACP) is a recommended practice in SA for patients with serious illnesses while they are still in good health and can function independently. Non-Governmental Organizations (NGOs) in SA have played a significant role in integrating ACP planning within their settings through advocacy and training. ACP has been included in both formal academic training and training programs offered by NGOs. Additionally, research has been initiated to evaluate the acceptability and validity of the Serious Illness Conversation Guide within the cultural diversity and complexities of the SA context. Acceptance of ACP amongst SA healthcare workers and the public faces many challenges. Many South Africans still have a low level of trust and acceptance towards the public healthcare system. In many South African cultures discussing death and dying is considered culturally taboo. Traditional cultures interpret and apply the concept of individual autonomy differently. The philosophy of "Ubuntu", which translates to "I am because we are", is widely endorsed in the country, prioritising community needs over individual needs. It is, therefore, essential for healthcare professionals engaging in ACP conversations not to make assumptions about a person's preferences for communication, decision-making and care, based on external attributes. Instead, they should respectfully explore these preferences and be adaptable in their approach to ACP. The implementation of ACP in SA is still in its early stages, requiring further research to inform culturally sensitive approaches to advance care planning.

Real-world experience implementing Advance Care Planning in the Asia-Pacific: ACP in Japan

Promoting Advance Care Planning (ACP) in the super-aged society of Japan has become increasingly important for supporting older adults to continue to live in the community until the end of life. To promote ACP further in Japan, Japanese family-centered decision-making and high-context culture need to be taken into account. Therefore, we describe the environmental and historical backgrounds surrounding ACP in Japan, and based on the results, introduce research and education programs regarding its implementation.

Advance Care Planning in Singapore: The genesis and evolution of a national programme

Singapore is a developed country that is aging rapidly. In 2011, a national programme in Advance Care Planning (ACP) known as Living Matters was launched. Over the years, the programme has grown and evolved. While ACP has become routine in some hospital units, challenges remain in implementing ACP as a standard of care across all levels of the healthcare system. Opportunities abound in improving the quality of the ACP process and in bringing ACP upstream into outpatient clinics, primary care and into the community.

Advance Care Planning in Germany

Advance Care Planning (ACP) defined as a comprehensive concept requiring a cultural change following implementation at the individual, institutional and regional level in order to achieve care consistency with care preferences when individuals are incapable of participating in critical decisions was first implemented in two regional projects (LIMITS and beizeiten begleiten, North Rhine Westphalia) in Germany in the 2000s. Based on the positive evaluation of beizeiten begleiten, legislation of 2015 (§ 132g, Social Code Book V) allows nursing homes and care homes for persons with disabilities to offer qualified ACP facilitation covered by the statutory health insurance. However, trainers for ACP facilitators need no specific qualification, and the training program for ACP facilitators is only broadly defined, which resulted in great heterogeneity of ACP facilitator qualifications. Furthermore, neither the institutional nor the regional implementation are sufficiently considered in this legislation, i.e. essential components of a successful implementation of ACP are missing. Nevertheless, a growing number of initiatives, research projects and a professional national society for ACP, engage in approaches to advance institutional and regional implementation, and to offer ACP to other target groups beyond the legal framework.

Advance Care Planning in the United Kingdom - A snapshot from the four UK nations

The United Kingdom (UK) as a whole has a long-established decades-old history as an early adopter of the concepts of Advance Care Planning (ACP), with significant integration into mainstream national policy and widespread implementation. The ACP term itself, its processes, means, inclusions and implementations vary considerably within the UK and between its four nations, but the overall impression is of a strongly uniting consensus on the positive impact, value and vital importance of ACP in enabling better care for people in the final years of life, and at earlier life stages. Though there is always more work to do and more lessons to learn, those of us who have watched this world-wide movement grow over recent decades, find the overall direction of travel of commitment to mainstreaming ACP in the UK to be inspiring and encouraging, and gives us hope for the future. Across the UK, there is much shared history, policy, objectives, and regulation related to ACP, and at the same time, many variations in approach, tone, emphasis and detail within and between the four nations of the UK. The 2022 Office of National Statistics reports that the four nations of the UK have a combined population of 67 million (England 56.5 million, Scotland 5.5 million, Wales 3.1 million, Northern Ireland 1.9 million). All four nations are prioritising ACP as part of national policy, aiming to deliver more personalised care, particularly but not exclusively for those nearing the end of life, with a wide variety of best practice examples. Here we describe some common areas and variations across the UK history, policy and legal perspectives, some examples of best practice, resources, and exciting developments across all four nations which, although not exhaustive and within the limitations of our brief, reflect the flavour of our shared commitment. We are most grateful to all the contributing authors.

Advance Care Planning in India: Current status and future directions. A short narrative review

India is undergoing economic, demographic and epidemiologic transitions. The healthcare industry is expanding rapidly as the burden of non-communicable diseases increases. The Indian Supreme Court [1] has recently enabled Advance Medical Directives (AMD). Implementation of Advance Care Planning (ACP) will depend on civil society and the palliative care sector until government support is available.

Advance Care Planning in Malaysia

BACKGROUND

In Malaysia, advance care planning is still in its infancy. There is no national implementation of Advance Care Planning.

AIMS

To describe the national state of advance care planning development in Malaysia METHODS: Review of relevant advance care planning literature locally and internationally was undertaken.

RESULTS

Positive development in Malaysia includes implementation of advance care planning at institutional level, initiatives to develop educational programmes as well as research activities to understand the attitude and perception of patients on advance care planning. However, there remain challenges, including lack of knowledge and awareness, lack of legislative framework to guide advance care planning implementation and lack of strong initiatives at a national level.

CONCLUSIONS

It is evident that there is much to learn nationally and internationally about ACP before any decision on implementation of ACP is made in Malaysia. ACP is a public health issue and requires concerted effort of all stakeholders, including Government agencies, academic institutions, and non-government organizations to raise public awareness. More research is needed to shape the future direction of ACP development in Malaysia.

Advance Care Planning in Taiwan

Taiwan has been promoting the concept of palliative care since 1983. In the 2021 global quality of death index, Taiwan ranked third. Regarding the development of patient autonomy, there are two phases. The first phase was the passage of the Hospice Palliative Care Act in 2000, which respects the personal choices of terminally ill patients, including the decision to refuse cardiopulmonary resuscitation and to withhold or withdraw life-sustaining treatment. The second phase was the passage of the Patient Right to Autonomy Act in 2015, which expanded the scope of application beyond terminally ill patients to include four other severe and irreversible conditions, while providing clearer explanations on life-sustaining treatment and artificial nutrition. Taiwan's legislation regarding the respect for patient autonomy has become increasingly comprehensive. However, there is still room for improvement in its practical implementation.