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Advance Care Planning (ACP)

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Advance Care Planning (ACP) Deborah Holman End of Life Care Specialist Nurse Gold Standards Framework Facilitator – PowerPoint PPT presentation

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Title: Advance Care Planning (ACP)


1
Advance Care Planning(ACP)
  • Deborah Holman
  • End of Life Care Specialist Nurse
  • Gold Standards Framework Facilitator

2
Our lives begin to end the day we become silent
about things that matter. -- Martin Luther
King, Jr.
3
What is ACP?
  • ACP is a process that aims to initiate
    conversations between individuals and their care
    providers.
  • Usually in the context of an anticipated
    deterioration in the individuals condition in
    the future.
  • According to personal preference an individual
    may or may not involve family and friends.
  • It is a tool for individuals to register their
    views and maintain their autonomy given that most
    elderly people have already given some thought to
    the end of their life.
  • It has the advantage of enabling individuals to
    influence their provision of care and shape the
    end of their lives according to their personal
    preferences and choices.

4
The key underpinning principals in this process
include
  • The process is voluntary and therefore no one is
    obligated to take part in this process.
  • Confidentiality must be respected.
  • The process is a reflection of societys desire
    to value individuals autonomy.
  • All health and social care workers should be open
    to any discussions that may be instigated by an
    individual and acquire the appropriate training
    to communicate effectively and understand the
    legal and ethical issues involved.
  • Each person must be aware of their own
    limitations and understanding.

5
  • Discussion should focus on the views of a
    competent individual even if family or carers are
    invited to participate. The discussion should
    only be instigated if it is in the best interests
    of the individual.
  • The individual must have the capacity to
    understand, discuss options and agree to whatever
    is planned. Individuals must be able to make
    informed decisions.
  • Agreement must be documented as must refusals to
    treatment.
  • Documented information should be made available
    to out of hours service providers to enable
    continuity.

6
Mental Capacity Act April 2007
  • To have mental capacity means that a person is
    able to make decisions for themselves. The legal
    definition says that someone who lacks capacity
    cannot do one or more of the following four
    things
  • Understand information given to them.
  • Retain that information long enough to be
    able to
  • make a decision.
  • Weigh up the information available to
    make a decision.
  • Communicate their decision. This
    could be by any
  • possible means, such as talking,
    using sign language or
  • even simple muscle movements such
    as blinking an eye
  • or squeezing a hand.

7
The mental capacity act has five main
principles
  • Assume a person has capacity unless proven
    otherwise
  • Do not treat a person as incapable of making a
    decision unless every attempt to help them has
    been made
  • Do not treat a person as incapable of making a
    decision because their decision may seem unwise
  • When making decisions for people without capacity
    always do so in their best interest
  • Before doing something to someone or making a
    decision on their behalf, consider whether you
    could achieve the outcome in a less restrictive
    way

8
Advance decisions and statementspreviously
known as living wills.
  • Living will is a legal document that spells out
    the types of medical treatments and
    life-sustaining measures you do and don't want.
  • Living wills became a catch all for
    general statements about persons wishes,
    preferences and specific refusals of treatment.
  • Not generally a term used by professionals
    now.
  • An Advance Decision allows you to record your
    wish to refuse certain types of medical
    treatment and will be binding on the people
    providing your care if you lose the capacity to
    make the decision at the relevant time.
  • An Advanced Statement allows you to record your
    personal wishes, preferences and views. It can
    relate to any part of your life and include your
    values and beliefs. It must be taken into account
    when making best interest decisions but is not
    legally binding.

9
It is still possible to make a advance decision
if a person is diagnosed with a mental illness,
as long as they can show that they understand the
implications of what they are doing.They need to
be competent to make the decision in question,
not necessarily to make other decisions.
  • Therefore it is preferable for such a person to
    put their
  • wishes in writing and explain
  • why they have made their decision about how they
    do/don't want to be treated
  • what they understand about the treatment they are
    agreeing to or refusing
  • why they are making these decisions now

10
Limitations on advance decisions
  • A person cannot use an advance decision to
  • ask for their life to be ended
  • force doctors to act against their professional
    judgment

11
Lasting Power of Attorney (LPA)
  • You can create two types of LPA
  • Property and Affairs LPAA Property and Affairs
    LPA allows you to choose someone to make
    decisions about how to spend your money and the
    way your property and affairs are managed.
  • Personal Welfare LPAA Personal Welfare LPA
    allows you to choose someone to make decisions
    about your healthcare and welfare. This includes
    decisions to refuse or consent to treatment on
    your behalf and deciding where you live. These
    decisions can only be taken on your behalf when
    the LPA is registered and you lack the capacity
    to make the decisions yourself.
  • LPA only be used after it is registered with the
    Office of Public Guardian.

12
The role of ACP in Gold Standard Framework (GSF).
  • Improving the pre-planning of care has been found
    to be one of the most important ways that we can
    ensure reliable patient-focused care.
  • GSF incorporates this thinking ahead approach
    as part of the process of best care.
  •  

13
The DNR question (Do Not Resuscitate)
  • Resuscitation is a medical procedure which seeks
    to restore cardiac and/or respiratory function to
    individuals who have sustained a cardiac and/or
    respiratory arrest.
  • The medical establishment supports the use of DNR
    orders on the basis either that these have been
    requested by the patient, or because the
    patients state of health is so poor that
    resuscitation would be futile.
  • However DNR should not be interpreted to mean do
    not treat.

14
Legally it is important to consider the
following
  • Resuscitation is to be considered a treatment
    like any other.
  • If a person is incompetent to discuss the issue
    the doctor must make a best interest decision
    based on his and other family/carer knowledge of
    the persons previous wishes.
  • A doctor is not obliged to provide futile
    treatment even if a person requests it.
  • A competent adult can refuse resuscitation.
  • No one can give or withhold consent for
    resuscitation on behalf of an incompetent adult.
    In particular family members can neither refuse
    nor demand such treatment. However, good medical
    practice dictates that a family should be
    involved in these discussions to maintain
    confidence and clarify, if necessary the persons
    likely wishes in the light of previous family
    discussion.

15
Palliative care complaintsIn a significant
amount of cases our advisors found that poor
communication limited a patients sense of
empowerment and their ability to make an informed
decision about their careHealth Care Commission
Spot light on complaints 2008
16
Research
  • Very little in the UK, mostly USA, Canada,
    Australia.
  • Views on elderly people on living wills
    interview study. Schiff et al 2000
  • Study of 74 people revealed that most elderly
    people have clear views on issues raised in
    living wills and 92 did not want their lives
    prolonged by medical intervention.
  • Planning for the end of life the views of older
    people about advance care statements. Seymour et
    al 2003
  • Study of 32 people revealed that such a document
    could help families and that they should be
    involved. Emphasis was made that a trusting
    relationship between participant and doctor was
    needed. However it was evident that ACP was
    better as a process rather than a once and for
    all decision.

17
  • ACP in care homes for older people a survey of
    practice. Froggatt et al 2008
  • This study showed that whilst many people were in
    favour of ACP and thought it was important the
    evidence that it happened was limited.
  • It also recommended that ACP be used on a wider
    scale i.e. primary care, public health.

18
Dilemmas
  • The process of ACP is highlighted as one of the
    most difficult areas for health care
    professionals.
  • Why? when patients have a moral right to
    information that concerns them, and doctors have
    no right to withhold such information?
  • We can rationalize why we shouldn't do it on the
    basis that withholding information is justified
    on the ethical grounds of beneficence.
  • There is evidence to prove that when patients
    were asked, most of them wanted full disclosure
    and most were dissatisfied when they didnt get
    it.
  • Will the unrealistic expectations of patients or
    families influence our decision making?
  • Whose responsibility is it to discuss end of life
    decisions anyway?
  • How open and honest should we be? Does it really
    matter?
  • Does it challenge our own mortality?
  • Difficult conversations need to be had we need
    to have the courage to have them.

19
They may forget what you said, but they
will never forget how you made them feel.

- Carl W. Buechner
20
Why is communication in EoLC different?
  • The subject can be taboo and not normally talked
    about
  • Emotions can run high and be unfamiliar and
    powerful
  • There are lots of players involved
  • The speed of events can make communication
    overwhelming
  • The finality of the subject matter
  • What is communicated is bad
  • The role can be unfamiliar to the nurse/carer
  • There needs to be a number of health care
    professionals involved
  • Partnership and permission needs to be created
    bringing trust into the relationship

21
The most important thing about communication
is to hear what isnt being said. Peter F.
Drucker
22
Blocks to communication
  • Behaviours/attitudes we should avoid include
  • Changing the subject - this blocks communication
  • Giving meaningless reassurance - this is not
    goal directed
  • Giving stereotypical replies - this confuses
    communication
  • Giving advice when not asked for - this is often
    not beneficial
  • Talking about yourself - this is irrelevant
  • Showing disapproval - this blocks communication
  • Passing judgement - this makes meaningful
    communication

  • impossible
  • Speaking and acting inconsistently - this
    confuses communication
  • Asking closed questions - this blocks
    communication

23
"Remember that silence is sometimes the best
answer."  - Dalai Lama
24
  • How people die remains in the memory of those
    who live on
  • Dame Cicely Saunders
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