Advance care planning is a process that enables individuals to make plans about their future

health care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health profe ...

. Advance care plans provide direction to healthcare professionals when a person is not in a position to make and/or communicate their own healthcare choices. Advance care planning is applicable to adults at all stages of life. Participation in advance care planning has been shown to reduce stress and anxiety for patients and their families, and lead to improvements in end of life care. Older adults are more directly concerned as they may experience a situation where advance care planning can be useful. However, a minority use them. A research conducted in Switzerland with people aged 71 to 80 showed that better knowledge on advance care planning dispositions could improve the perception older people have of them. Communication on dispositions should take into account individual knowledge levels and address commonly enunciated barriers that seem to diminish with increased knowledge. The main components of advance care planning include the nomination of a substitute decision maker, and the completion of an advance care directive.

Background

Advance care planning is applicable to all adults in all stages of life. Advance care planning aims to allow people to live well, and when death approaches, die in accordance with their personal values. Advance care planning is only applicable when the individual cannot make and/or communicate decisions about what they want in relation to their healthcare. If advance care planning has occurred, patients who have lost capacity or the ability to communicate or both, are able to continue to have a say in their medical care. This has been shown to improve end of life care, and provide improved outcomes for both patients and their surviving relatives. While applicable to all stages of life, it is particularly applicable to

perioperative The perioperative period is the time period of a patient's surgical procedure. It commonly includes ward admission, anesthesia, surgery, and recovery. Perioperative may refer to the three phases of surgery: preoperative, intraoperative, and posto ...

planning and

end-of-life care End-of-life care (EoLC) refers to health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotio ...

decision making, since approximately 1 in 4 people lose decision making capacity when approaching the end of their life. Results of a systematic review indicate there are several prognostic indicators to help identify patients who may benefit from advance care planning discussions while still in the

primary care Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care t ...

setting. Although ACP is potentially appropriate for nearly all adult patients, given the realities of a busy practice, it would be useful to have a system for identifying patients with a more limited prognosis. Federal and state

legislation Legislation is the process or result of enrolled bill, enrolling, enactment of a bill, enacting, or promulgation, promulgating laws by a legislature, parliament, or analogous Government, governing body. Before an item of legislation becomes law i ...

in the US,

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and the UK supports the right of

patient A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health c ...

s to refuse unwanted medical treatments. People can also express their preferences through written advance directives or by advising their appointed substitute decision maker about their wishes for when they are unable to make or communicate these decisions/wishes themselves.

Components

There are two methods by which the communication of an individual's preferences can be known. These are: # the appointment of a substitute decision maker, and # the completion of an advance care directive or similar document. Findings from a systematic review suggest the value and importance that various types of decision aids have for patients to use and help clarify their goals.

Substitute decision maker

A substitute decision maker makes decisions on behalf of an individual only when that individual does not have the capacity to make/communicate decisions for themselves. There are a number of methods by which a substitute decision maker can be identified. The ideal method is the appointment of a person using a statutory document. In the absence of a

statutory A statute is a formal written enactment of a legislative authority that governs the legal entities of a city, state, or country by way of consent. Typically, statutes command or prohibit something, or declare policy. Statutes are rules made by le ...

document the substitute decision maker may be a "person responsible" as listed in order of authority in legislation. A substitute decision maker can be chosen by an individual following completion of relevant paperwork, can be assigned to the person by law in the absence of a chosen substitute decision maker (e.g. family member or carer), or can be appointed for the person (e.g.

guardian Guardian usually refers to: * Legal guardian, a person with the authority and duty to care for the interests of another * ''The Guardian'', a British daily newspaper (The) Guardian(s) may also refer to: Places * Guardian, West Virginia, Unite ...

appointed by a guardianship tribunal). Substitute decision makers make decisions based on the principles of either substituted judgement or

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. Substituted judgement is when the substitute decision maker arrives at a decision based on the best approximation of what they believe the person would want. This decision should be informed by both the known wishes of the person and the best available healthcare advice. Best interests decision making requires the substitute decision maker to focus on the patient's best interests. Many, but not all, jurisdictions have legislation supporting the appointment of a substitute decision maker through a

document. They have different names depending on the jurisdiction:

Advance care directives

An advance care directive is a document detailing an individual's health care preferences. This may include personal values and life goals, describe circumstances the person would find unacceptable, identify preferences relating to specific medical interventions, or a combination of these. Advance care directives may be written on specifically designed forms, but can also take the form of a written letter or statement. Inclusion of a doctor in the completion of an advance care directive will assist in ensuring that an individual's wishes are clear and written in a manner that is easy for substitute decision makers and/or medical staff to interpret and follow them in the future. Having a

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witness the document will reinforce this by showing future medical staff that the document contains information about informed decisions due to the assistance of a physician.

Advance Decisions to Refuse Treatment (United Kingdom)

Some countries do not use the term 'directive', due to advance statements and/or advance care plans not usually having the legal standing to enforce a directive (for instance, a patient cannot ''direct'' a doctor to give him a specific treatment at a later time-point i.e. when she/he loses decisional capacity). In the United Kingdom, Advance Decisions, or Advance Decisions to Refuse Treatment (short: 'ADRT') have a legal standing under the UK Mental Capacity Act (2005). They can be written down and signed by patients. Such an ADRT must be specific about the treatment that is being refused and the circumstances in which the refusal will apply. To be valid, the person must have been competent and understood the decision when they signed the ADRT. Where the patient's advance decision relates to a refusal of potentially life-saving or life prolonging treatment, this must be recorded in writing and witnessed. Any advance refusal is legally binding, providing that the patient is an adult, the patient was competent and properly informed when reaching the prior decision. It is clearly applicable to the present circumstances and there is no reason to believe that the patient has changed their mind. If an advance decision does not meet these criteria but appears to set out a clear indication of the patient's wishes, it will not be legally binding but should be taken into consideration in determining the patient's best interests.

Benefits

Advance care planning for adults with heart failure

The latest evidence indicates that advance care planning (ACP) may help to increase documentation by medical staff regarding discussions with participants, and improve an individual's depression. This involves discussing an individual's future care plan in consideration of the individual's preferences and values. The findings are however, based on low-quality evidence as there is a need for further evidence from large studies to fully explore the effects of ACP for older adults.

References

{{reflist Health law in the United States Health law in the United Kingdom