Support your patients with advance care planning
Dr Karen Detering implores GPs to leverage off their ongoing and trusted relationships with their patients, and start the conversation about advance care plans.
Advance care planning is about patient-centred care. It’s the process of planning for future health and personal care. It usually involves a person choosing, preparing, and appointing a substitute decision-maker and putting their healthcare preferences in writing. These can be broad and include the person’s goals, values, and outcomes from care or they can be specific treatment preferences.
Everyone should consider advance care planning regardless of their age or health. These conversations can take place among loved ones outside the health sphere, but general practitioners (GP) are in a great position to support advance care planning.
You may be surprised that it’s easier than you think, and it can be uplifting for both you and your patients.
GPs have an important and trusted relationship with their patients. Not only are GPs informed about their patients’ current health, they can prognosticate potential future health developments and needs, and in many states and territories, advance care directives need to be signed by a doctor.
So, who needs advance care planning?
While advance care planning can be considered by anyone anytime, it is particularly important in the following scenarios:
- If the patient raises advance care planning with a member of the general practice team
- Has a life limiting illness or progressive illness (e.g. COPD, heart failure, dementia or advanced cancer)
- Is aged 75 years or older, or 55 years or older if they are an Aboriginal and/or Torres Strait Islander person
- Is a resident of, or is about to enter, an aged care facility
- Is at risk of losing competence (e.g. has early dementia)
- Has a new significant diagnosis (e.g. metastatic disease, transient ischemic attack)
- Is at a key point in their illness trajectory (e.g. recent or repeated hospitalisation)
- Does not have anyone (e.g. family, caregiver, friend) who could act as substitute decision maker
- May anticipate decision-making conflict about their future health care
- If the patient is frail or has a carer
Advance care planning doesn’t have to happen all at once! It’s a process that may develop over time. Early advance care planning may only involve conversations. Later, a patient might appoint a substitute decision-maker, and outline what is most important to them. When a patient develops an illness, they may then choose to create a more detailed treatment plan.
Identifying opportunities for conversations
Listen for potential conversation triggers. For example, if a patient says they are struggling with treatment or doesn’t want to return to hospital, you can use these opportunities to introduce the topic. Questions you could ask include:
- I try to talk to all my patients about what they would want if they became more unwell. Have you ever thought about this?
- Who would you like me to talk to if you were unable to talk to me about important medical treatment decisions?
- What does it mean to you to ‘live well’? What are your goals at this time?
- What do you understand about where things stand right now with your illness?
- Does your family (or caregivers or friends) know what you would want?
Appointing a substitute decision-maker
A substitute-decision maker is the voice of the patient when they can no longer make their own decisions. The substitute decision-maker should be someone that the patient trusts to express the patient’s treatment preferences and who will faithfully make difficult decisions on behalf of the patient who no longer has capacity.
In all states and territories in Australia, it is possible to legally appoint a substitute decision-maker, but their authority varies by jurisdiction.
Developing an advance care plan
Any person over 18 years of age with capacity can make an advance care directive. In Victoria, from 12 March 2018, people under 18 can also make an advance care directive if they are deemed to have medical decision-making capacity.
There are two forms of statement that a person can create: a values directive and an instructional directive. A values directive contains general statements about their preferences, values, and what matters to them. In an instructional directive, a person may consent to or refuse particular medical treatments. Specific details regarding the legislation varies throughout Australia, so it’s important to check the guidelines in your state. The Advance Care Planning Australia website contains state-specific resources that patients and professionals can access.
A lawyer is not required to create an advance care directive. In some jurisdictions, a doctor is required to sign an advance care directive. In jurisdictions that do not require a doctor’s signature, an advance care directive should, ideally, be discussed with a doctor as this ensures that any decisions made will be made on the basis of correct medical information. It also ensures that the treating doctor is fully aware of the patient’s preferences and therefore better able to provide medical care that takes these preferences into account.
Patients making decisions based on good medical information will help future doctors to follow a directive with confidence.
Get involved in the conversation
Advance care planning is about relationships between individuals, their families and carers, and health professionals, and is important for all Australians. Each group has its own roles and responsibilities to ensure that Australians' healthcare preferences are respected. Everyone needs to work together to put patients at the centre.
GPs should apply their skills to get conversations started. You may be surprised that it’s easier than you think, and it can be uplifting for both you and your patients.
To learn more about advance care planning click here
Dr Karen Detering
Dr Karen Detering is the Medical Director of Advance Care Planning Australia. Karen is a Respiratory Physician and Clinical Ethicist and has specialised in advance care planning for over 14 years. Karen works in education, implementation, evaluation and research to ensure all Australians are enabled to undertake advance care planning.