Advance Care Planning

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Advance Care Planning
Dr Regina McQuillan FRCPI
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What is planned?

• Why?
• Who?
• How?
• When?
• Where?

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Advance Care Planning

• Decisions made now, in anticipation of changing
  health status, when it is expected the patient or
  decision makers will not be in a position to make
  the same carefully reasoned decision.

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What is planned?

• Level of intervention for investigation or
  treatment
• Place of care
• Place of residence

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Interventions - General

• Hospital transfer
• Intravenous antibiotics
• Intravenous fluids
• Subcutaneous fluids
• Gastrostomy (PEG or RIG)
• Ventilation

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Interventions - Specific

• To address likely outcomes of particular illness

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Motor Neurone Disease

• Gastrostomy
• Non-Invasive ventilation (NIPPY)
• Invasive ventilation

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Implanted Cardiac Debrillators

• Switching off

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Chronic Obstructive Pulmonary Disease

• Ventilation
• ICU

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Dementia

• Tube Feeding
• Intravenous Antibiotics
• Hospital Admission

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Why engage in Advance Care Planning?

• Appropriate planned decisions

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Why engage in Advance Care Planning?

• No legal or ethical obligation to provide all
  possible treatment
• No obligation to provide futile treatment
• Patient has the right to refuse treatment, even
  if life prolonging.

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Who makes the plan?

• Patient
• Doctor
• Multidisciplinary Team
• Family
• Hospital Team

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Who makes the plan?

• No one has the legal right or responsibility to
  make decisions about others health

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When should plan be made?

• Dependent on illness natural history
• Changes in health status eg hospital/nursing
  home admission
• Markers of deteriorating health

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Where should plan be made?

• Place of care
• May be by joint, if patient moves from one care
  setting to another

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How should plan be made?

• Most Important

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How should plan be made?

• If patient not competent
• - Doctor makes decision, in best interest of the
  patient, taking the known wishes and values of
  the patient into account, following wide
  consultation with family and the
  multidisciplinary team.

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How should plan be made?

• May be done in stages
• Rarely emergency or urgent

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How should plan be made?

• Clearly documented
• Consider transfer document

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How should plan be made?

• Reviewed as health status changes

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Scope of Advance Care Plans

• Must be legal

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Scope of Advance Care Plans

• Must be ethical
• - respect the autonomony of others
• - cannot require family to give all care,
• cannot require health care workers to
• treat patient unethically
• - respect distributive justice

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Resources

• www.bioethics.ie
•  www.resus.org/pages/dnar.htm
• www.endoflifecareforadults.nhs.uk