Advance Care Planning
Dr Regina McQuillan FRCPI
What is planned?
Why?
 Who?
 How?
 When?
 Where?

Advance 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?
Level of intervention for investigation or
treatment
 Place of care
 Place of residence

Interventions - General
Hospital transfer
 Intravenous antibiotics
 Intravenous fluids
 Subcutaneous fluids
 Gastrostomy (PEG or RIG)
 Ventilation

Interventions - Specific

To address likely outcomes of particular
illness
Motor Neurone Disease
Gastrostomy
 Non-Invasive ventilation (NIPPY)
 Invasive ventilation

Implanted Cardiac Debrillators

Switching off
Chronic Obstructive Pulmonary
Disease
Ventilation
 ICU

Dementia
Tube Feeding
 Intravenous Antibiotics
 Hospital Admission

Why engage in Advance Care Planning?

Appropriate planned decisions
Why engage in Advance Care Planning?
No legal or ethical obligation to provide
all possible treatment
 No obligation to provide futile treatment
 Patient has the right to refuse treatment,
even if life prolonging.

Who makes the plan?
Patient
 Doctor
 Multidisciplinary Team
 Family
 Hospital Team

Who makes the plan?

No one has the legal right or
responsibility to make decisions about
others health
When should plan be made?
Dependent on illness – natural history
 Changes in health status – eg
hospital/nursing home admission
 Markers of deteriorating health

Where should plan be made?
Place of care
 May be by joint, if patient moves from one
care setting to another

How should plan be made?

Most Important
How should plan be 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 made?
May be done in stages
 Rarely emergency or urgent

How should plan be made?
Clearly documented
 Consider ‘transfer document’

How should plan be made?

Reviewed as health status changes
Scope of Advance Care Plans

Must be legal
Scope of Advance Care Plans

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
Resources
www.bioethics.ie
 www.resus.org/pages/dnar.htm
 www.endoflifecareforadults.nhs.uk
