Advance Care PlanningAdvance Care Planning

Dr Regina McQuillan FRCPI

What is planned?What is planned?Why?Who?How?When?Where?

Advance Care PlanningAdvance 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.

What is planned?What is planned?Level of intervention for

investigation or treatmentPlace of carePlace of residence

Interventions - GeneralInterventions - GeneralHospital transferIntravenous antibioticsIntravenous fluidsSubcutaneous fluidsGastrostomy (PEG or RIG)Ventilation

Interventions - SpecificInterventions - SpecificTo address likely outcomes of

particular illness

Motor Neurone DiseaseMotor Neurone DiseaseGastrostomyNon-Invasive ventilation (NIPPY)Invasive ventilation

Implanted Cardiac Implanted Cardiac DebrillatorsDebrillatorsSwitching off

Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary DiseaseDiseaseVentilationICU

DementiaDementiaTube FeedingIntravenous AntibioticsHospital Admission

Why engage in Advance Care Why engage in Advance Care Planning?Planning?Appropriate planned decisions

Why engage in Advance Care Why engage in Advance Care Planning?Planning?No legal or ethical obligation to

provide all possible treatmentNo obligation to provide futile

treatmentPatient has the right to refuse

treatment, even if life prolonging.

Who makes the plan?Who makes the plan?

PatientDoctorMultidisciplinary TeamFamilyHospital Team

Who makes the plan?Who makes the plan?

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

When should plan be When should plan be made?made?

Dependent on illness – natural history

Changes in health status – eg hospital/nursing home admission

Markers of deteriorating health

Where should plan be Where should plan be made?made?

Place of careMay be by joint, if patient moves

from one care setting to another

How should plan be How should plan be made?made?

Most Important

How should plan be How should plan be made?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.

How should plan be How should plan be made?made?

May be done in stagesRarely emergency or urgent

How should plan be How should plan be made?made?

Clearly documentedConsider ‘transfer document’

How should plan be How should plan be made?made?

Reviewed as health status changes

Scope of Advance Care Scope of Advance Care PlansPlans

Must be legal

Scope of Advance Care Scope of Advance Care PlansPlans

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

ResourcesResources

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