Primary Care Resources - Advance Care Plan

An advance care plan is a written document which sets out a person’s wishes with regards to personal care and medical treatment. This document may include the person’s beliefs, values, and goals and will inform a substitute decision maker with respect to care decisions. The advance care plan can also be shared with health professionals; however, it is not a substitute for consent to treatment or personal care.(2) Advance care planning is a process; through reflection and communication a plan is developed.  In addition to the individual, advance care planning can involve family members, health professionals and financial or legal advisors, lawyers, or powers of attorney. (1)

Why is it important?

  • Health care decision are becoming increasingly complex; advances in medical technology mean that people with complex conditions live longer, resulting in 73% of Canadians dying from chronic disease- this translates into a large proportion of Canadians who cannot make their own decisions near death (2)
  • 86% of Canadians have not heard of advance care planning and less than half have had a discussion with a family member or friend about healthcare treatments if they were ill and unable to communicate (2)
  • 52% of Canadians indicate that the advance care planning process should begin when a person is healthy, yet only 13% have an advance care plan prepared
  • Patients who have end-of-life conversations with their doctors/family members are much more likely to be satisfied with care received, require fewer aggressive interventions at end of life, are more likely to take advantage of hospice resources resulting in less strain on caregivers (1)
  • End-of-life discussions and advance care planning can reduce moral distress for healthcare providers; affect outcomes such as completion of advance directives or powers of attorney for personal care; improve adherence to individual’s wishes (2)

Key Considerations

  • Conversation should occur in non-stressful environment; focus on patient’s principles and values and beliefs around end-of-life and what makes patient’s life meaningful;  determine if the circumstances and burden of treatment outweighs the benefits of prolonged life; assess quality of life and discuss how the patient wants to live during the  final stages (e.g. at home, pain-free) (2)
  • Focus on personal care: review possible treatments that may be considered for patient’s condition, discuss implication of possible medical treatment (e.g. artificial ventilation, hydration, cardiopulmonary resuscitation), specify wishes with respect to organ donation or research participation, include patient’s values, culture, faith and beliefs when discussing possible decisions (2)
  • Discuss patient’s choices with close family members and those that will be called upon in the event of incapacity
  • Health care provider should document discussions and decisions of the advance care plan in the medical record and provide the patient with a copy;  if they choose, it can be shared with family, loved ones, or substitute decision makers; periodically review and update the advance care plan (2)
  • Use the advance care plan to inform advance directives (e.g. when naming a substitute decision maker in the Power of Attorney for Personal Care) (2)
  • Advance Care Planning in Canada: National Framework builds on the following:(2)
    1.  Engagement: healthcare system and legal system
    2.  Education: training of professional providers and educating general public
    3.  System Infrastructure: policy and program development, tools to support conversations
    4.  Continuous Quality Improvement
  • Other helpful tools are available at:  http://www.chpca.net/media/7452/acp_synthesis_of_tools_march_22_10.pdf

References

1.     Canadian Hospice Palliative Care Association. (2013).  Advance Care Planning Fact Sheet.
         Retrieved March 17, 2014 

2.     Canadian Hospice Palliative Care Association. (2012). Advance Care Planning in Canada: National Framework.
        Retrieved March 17, 2014