What Are the Advantages of Advance Care Planning?
If a person was unwell and not able to communicate their preferences to others, how could we know what they'd want? Who would speak for them? Advance care planning ensures that the person you are caring for, their family, friends and/or carer know what the person's health and care choices really are. That can give everyone some peace of mind. Advance care planning is particularly important for people who are older and are frail, or people who have a chronic illness, multiple diseases, an early cognitive impairment, or are approaching their end of life.
Successful ACP programs not only ensure that doctors, patients, and families talk about future care but also that the content of those conversations is documented in a fashion that travels with the patient as they move across health care settings. Documentation by medical staff of prior discussions with patients about their goals for medical care, as well as their values and beliefs, can also assist greatly in decision-making if the individual loses the ability to participate in medical decision-making in the future. Ideally, an ACP discussion is followed by specific, actionable medical treatment orders (eg, Do-Not-Resuscitate [DNR] orders) reflecting a person’s treatment preferences and current medical condition. Medical treatment orders should be written in a standardized format that is readily understood by health care professionals during an emergency. ACP can include completion of an advance directive (AD), where patients document their preferences for medical care and appoint a surrogate decision-maker. There are various kinds of ADs, but the types typically recognized by state law in the United States are the Living Will (LW) and the Durable Power of Attorney for Health Care (DPAHC). LWs document patient preferences for life-sustaining treatments and resuscitation. DPAHCs (also known as “Health Care Proxy Designations”) document their choice of a surrogate decision-maker. The major limitation of the LW is that it may not be applicable to every decisional dilemma the patient will actually face. For that reason, the designation of a surrogate decision-maker is especially important; surrogate decision-makers can provide guidance to medical teams in cases where patients are incapacitated and the LW does not apply. Asking a patient to consider their goals, values, and beliefs, and how these may influence their future medical decisions, is helpful and may be a good place to start the conversation. Although the provider who engages in this discussion with the patient regarding ACP need not be a clinician, ideally it should be a health care provider who is able to work in collaboration with the medical team and who can provide information about prognosis and outline the medical options and their benefits and risks . Additionally, the process need not occur with a single visit or a single provider but can occur across multiple visits and providers who coordinate the patient’s care.
The process of advance care planning in dementia is far from straightforward; as dementia progresses, the ability to consider future thoughts and actions becomes compromised, thus affecting decision-making abilities (Shalowitz DI, 2006). Family carers find themselves increasingly in a position where they need to inform, or directly make, decisions on behalf of the person with dementia. It is estimated that there are currently 44.4 million people worldwide with dementia, and (if mortality, prevention and treatment remain the same) this number will increase to an estimated 75.6 million in 2030 and 135.5 million in 2050. Dementia is a term used to describe a syndrome, a collection of symptoms, including a decline in memory, reasoning and communication skills, and a gradual loss of skills needed to carry out daily living activities. These symptoms are caused by structural and chemical changes within the brain as a result of neurodegenerative changes and as such dementia is the end-stage manifestation of numerous brain disorders. Increasing numbers of people will die with (or from) dementia. Estimates from the UK Medical Research Council–Cognitive Function and Ageing Studies (MRC–CFAS), a large multicentre research programme examining the health and cognitive function of 13,000 older people, suggest that people who died between the ages of 65 and 69 years had a 6% risk of dying with or from dementia, rising to a 58% risk in those over 95 years. This means that, in the United Kingdom, one in three people over the age of 65 will die with or from dementia (Harrison Dening K, King M, 2016).
In brief, advance Care Planning will help patient to overcome family conflicts, relieves burden from family or healthcare teams to make decisions in stressful situations, improve patient and family satisfaction with care and treatment, and reduce stress, anxiety, and depression within family. Nursing care plans will help patient to achieve quality of life and ensure patient wishes and preferences are understood and respected by everyone during end-of-life care. Nursing diagnosis is implemented by keeping patient at the centre of care to provide better quality of care according to patient’s wishes documented in advance care directives. Moreover, barriers and facilitators related to Carla’s case study and advance care planning helped to implement effective client-centred care.
Shalowitz DI, Garrett-Mayer AB, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 2006; 166: 493–497.
Harrison Dening K, King M, Jones L, et al. Advance care planning in dementia: do family carers know the treatment preferences of people with early dementia? PLoS ONE 2016
Ditto PH, Danks JH, Smucker WD, et al. Advance directives as acts of communication: a randomized control trial. Arch Intern Med 2001
Webb R, Harrison Dening K. In whose best interests? A case study of a family affected by dementia. Br J Community Nurs 2016; 21: 300–304.
Livingston G, Leavey G, Manela M, et al. Making decisions for people with dementia who lack capacity: qualitative study of family carers in UK. BMJ 2010;