Advance care planning is a process that enables individuals to make plans about their future health care. 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 end-of-life caredecision making, since approximately 1 in 4 people lose decision making capacity when approaching the end of their life. Federal and state legislation in the US, Australia, Canada and the UK supports the right of patients 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.
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 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, or can be appointed for the person Substitute decision makers make decisions based on the principles of either substituted judgement or best interests. 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 statutory 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 physician 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.
