Medical care of older persons in residential facilities

Advance care planning

Advance care planning enables people to prepare for, and make choices about, the type of future medical treatment they wish to have, or refuse, if they become unable to make their wishes known. There are two aspects to advance care planning-proxy directives and instructional directives. Proxy directives grant legal authority to another person to be responsible for health or personal care decisions. Instructional directives give explicit treatment instructions, eg. advance directive, advance care plan or living will; refusal of treatment certificate; and do not resuscitate orders.

Advance care planning involves discussions with patients about their medical history and condition, values, and preferences for future medical care. This is done in consultation with health care providers, family members and other significant people in their lives.

In Australia, there is strong support for advance care planning from both health professionals and the general community.⁴⁶ Awareness of advance care planning across health settings and the community is growing nationally, with the dissemination of programs such as 'Respecting patient choices', piloted by the Austin and Repatriation Medical Centre in Victoria.⁴⁷

Increasingly, advance care planning is being incorporated into routine care of patients in RACFs. Many facilities ask about and record residents' wishes on admission. Some residents may already have an authorised representative or advance care plan. For residents who do not possess the capacity to make their wishes known, and have not appointed a representative, most states have legislation to determine who is legally authorised to make medical treatment decisions on their behalf.

General practitioners can become familiar with the particular legal requirements in their state or territory by referring to Table 2, and contacting relevant guardianship authorities for up-to-date information (see Contacts). The role of GPs in advance care planning may include:

discussing the idea of advance care planning with residents
providing residents with information regarding their current health status, prognosis and future treatment options
witnessing or completing instructional directives where appropriate
applying residents' wishes to medical management.

Discussion leading to an advance care plan may occur over several occasions, and cover the following aspects:

Introduce advance care planning: Ask residents if they have thought about their choices of medical treatment in the future
Experience of end of life decision making: Ask residents if they have had any experience with a family member or friend who was faced with a decision about medical care near the end of life. If yes, ask them if the experience was positive or if they wish things could have been different, and how
Selecting a representative: Provide information on appointing a representative. Ask whom they would like to make decisions for them if they were unable to make their own choices known. If they have someone in mind, recommend that they discuss their wishes with their potential representative
Making decisions about future care: Ask how they would like decisions to be made if they could not make those decisions
Goals and values: Ask what types of things and activities give life meaning (use relevant example)
Religious, spiritual and cultural beliefs: Ask who or what sustains them when they face serious challenges in life. Is there someone they would like to speak with to help them think about these issues. Cultural customs may differ with respect to patient autonomy, informed decision making, truth telling and control over the dying process.

It is prudent to discuss the plan with relatives or carers to avoid any disagreement or potential conflicts that could arise. Residents can change their advance care plan, as long as they are capable. If a change is made, then a copy must be given to all relevant people (representative, GP, RACF, other relevant health care providers).

Some people may wish to discuss euthanasia. It is important to differentiate this from advance care planning, palliative care and end of life care. There is a significant ethical and legal difference between the concept of an advance care plan and the issue of euthanasia. Advance care planning is a fundamental and legitimate right of patients to accept or reject treatment options. This is in contrast with euthanasia where the primary purpose is to actively cause or hasten death. Euthanasia is illegal in Australia.⁴⁸ A summary of GP steps to advance care planning is given below.⁴⁹

Step 1. Incorporate advance care planning as part of routine care of residents

Provide information and offer advance care planning when doing a comprehensive medical assessment
Suggest that the representative or family be involved in future consultations about the resident's wishes

Step 2. Assess capacity of resident to appoint a representative and complete an advance care plan

Where residents have the capacity, check and witness that the representative/s is/are appropriate and agree, and that the appropriate form has been completed correctly
Where residents do not have capacity, refer to state legislation for who can be the representative (see Table 2)

Step 3. Support discussion and documentation of advance care plan

Discuss the resident's wishes with resident, representative, relatives'carers, and RACF staff
Provide information on medical conditions, benefits and burdens of treatment
Review advance care plan
Complete relevant forms, eg. refusal of treatment and/or not for resuscitation if appropriate

Step 4. Apply the resident's wishes to medical care

Advance care plans only come into use when residents are no longer able to communicate their wishes
Consult advance care plans and resident'representative'relatives when major clinical decisions need to be made

Step 5. Review plan regularly or when health status changes significantly (can be revoked at any time as long as the resident is capable).

Table Two: Summary of state legislation affecting advance care planning (as at 2004) ⁵⁰

State	Advance Care Plan (ACP)	Proxy	Comments
VIC	Yes	Yes	Medical Treatment (Enduring Power of Attorney) Act 1990 allows appointment of proxy (representative). Patient can write a 'refusal of treatment' certificate, but only for a current illness that does not have to be terminal
SA	Yes	Yes	Consent to Medical Treatment and Palliative Care Act 1995 confirms that a person over 18 years of age can write an ACP but only for a terminal illness
NT	Yes	No	NT Natural Death Act 1988 allows a person 18 years and over to make an ACP to refuse extraordinary treatment in the event of illness
ACT	Yes	Yes	Medical Treatment Act allows for refusal of treatment. Protects health professionals who withhold/withdraw treatment at patient's request
QLD	Yes	Yes	Powers of Attorney Act 1998 allows ACP and proxy for health/personal matters. Guardianship and Administration Act 2000 (and amendments 2001) increased scope. Proxy can now consent to withdrawing/withholding life sustaining treatment
NSW	Yes	Yes	ACPs that comply with the requirements of the NSW health document Using Advance Care Directives (2004) are legally binding. Individuals may also appoint their own enduring guardian
TAS	No	No	No current legislation. Medical Treatment and Natural Death Bill (1990) not passed by Parliament. Tasmanian health department has 'dying with dignity' guidelines that recommend respecting ACP
WA	No	No	No current legislation. Private Members Bill for refusal of treatment by terminally ill people (Medical Care of the Dying Bill 1995) passed by Lower House November 1995, lapsed when election called. This bill recommended patients are able to refuse palliative care

Please note: This table is intended to provide a brief overview only. It should not be relied on as legal advice. You should consult your own legal advisor for guidance on the law as it provides to the facts and circumstances of a particular case.