Steps
Example phrases
Open the discussion
• Right now you’re healthy. This is a good time to think about your health in the future. It’s often easier to talk when there isn’t a crisis
• Have you heard the term advance care planning? It involves thinking about and planning for your future medical care in case you aren’t able to make decisions later
• Have you ever thought about your wishes for care in case you became suddenly unwell?
Gain patient acceptance for discussion
• “ACP gives everyone involved in caring for you a clear understanding of your wishes so that you don’t get care that you do not want. Would you be interested in talking about what care you might want in the future?”
• How do you feel about discussing these issues now?
• Is there anyone you would like to be present when we discuss this?
Establish understanding of ACP and their current and future health status
• If you got sick how much information would you want to know about your illness and what to expect in the future?
• Have you ever had a discussion with anyone about what you medical care you might want if you became too sick to make decisions?
• What do you know about your current health status, and what you might expect over the next 12 months?
Elicit the patient’s values, beliefs and experiences
• How much would you want to be involved in decisions about your healthcare?
• Is there anyone else you rely on to help you make important decisions? Would you prefer that person to follow your wishes exactly, or to use their own judgment?
• What are the most important things that you want your friends, family and/or doctors to know about how you would like to be cared for if you were dying?
Prepare and complete advance care planning documents
• So I think I understand your main goal is to that you don’t want to get to the point where you are unable to communicate or recognise your family or friend. Is this right?
• It’s really helpful if we can write down what we have discussed today so that everyone knows what you your preferences are and how you want decisions to be made.
• It’s really important that your family are aware that you have prepared these documents and that they know where to find them.
Review and update regularly
• Even though we have talked today about what you might want if your circumstances change, you can always change your mind and we can make a new plan
• Let’s think this over the next few weeks and talk again when we next meet.
• These are decisions that might change depending on how you are going. We can revisit this as often as you want.
Applying ACP to the Case Study
Fortunately Mr. Smith had an enduring power of attorney and advance care plan that was documented well and witnessed by a solicitor. This had been reviewed during the preceding 6 months.
The family advised that he had told them that he did not want to prolong his life, and they wanted him to be kept comfortable if the medical treatment did not improve the situation. They produced a copy of his “enduring power of attorney” witnessed by his solicitor 3 years previously. His wife and eldest daughters were his legal guardians. This document stated the family could decide where he will live, the healthcare he will receive and whether to have or refuse treatment. It also stated if he is in a terminal phase of any incurable illness or in a coma or unlikely to recover, he did not wish to have any medical treatment (even if it was going to prolong his life) other than palliative care. He had clearly stated in the document that in this situation he did not want to receive any artificial hydration or resuscitation.
The family requested all his medications to be withdrawn and he be kept comfortable. The treating team decided that this was the best thing to do and further medical treatment was futile. Mr. Smith received comfort care and was kept pain-free. All blood tests were cancelled and intravenous lines were removed.
He died peacefully surrounded by Mrs. Smith and his daughters. The family thanked the team for caring for him and providing him “good death” after 88 years of good life.
References
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