Advance Care Planning
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Advance Care Planning
“Caring for people at the end of their
lives is an important role for many health
and social care professionals. One of the
key aspects of this role is to discuss with
individuals their preferences regarding
the type of care they receive and where
they wish to be cared for”
(Mike Richards 2007)
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
What is Advance Care Planning
Advance care planning (ACP) is a discussion
between an individual and their carers which
identifies
Wishes/values
Concerns
Preferences for care
-and will generally take place in anticipation of
a future deterioration in a persons condition
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Advance Care planning
- Formalize what patients and their
family do wish to happen to them
Advance
statement
- Can be useful to clinicians in planning
of patient’s individual care
- Not legally binding and may also need
Advanced Directive and DNAR
Advance
Care Planning
Advance
Decisions
- Formalizes what patients do not wish
to happen to them
- Legally binding document
- Related to capacity of decision making,
Mental Capacity Act, Living Will etc.
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Different Aspects of Advance Care Planning
Opening conversation
Exploring options
Identifying wishes and preferences
Refusing specific treatment
Asking someone to speak for you
Appointing a Lasting Power of Attorney
Letting people know
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Advance Statement of Wishes and
Preferences
A record reflecting an individuals preferences and
aspirations
Can help professionals identify/review how individuals
wish to be cared for ( NB. Best interests)
Not legally binding but has legal standing
If requested it can be shared with relatives and
others and can promote important discussions with
family members
May lead to an advance decision to refuse treatment.
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Issues associated with ACP
Some of the issues identified through pilots using ACP
When to introduce the idea of an Advance Care Plan
By whom
Poor communication skills
Fear of talking about future care
Fear of causing distress
Conflict between family members
Raising expectations
Documentation methods
Sharing information
Time
ADRT
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Skills required for successful
advance care planning
Professional aware of their own limitations
Choose time/setting appropriately
Professional fully informed of patients illness,
treatment options and prognosis
Professional aware of or identifies through discussion
patients level of understanding
Professional aware of patients social situation and
things which may influence wishes.
Cont.---North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
cont. skills required for
successful advance care planning
Accept ACP may require more than one discussion
Discussion may lead to request for family to be
present
Side tracking may occur
Do not be judgemental but encourage realistic wishes
Identify possible issues and discuss possible solutions
Listen for and follow up ‘cues’
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Listen for and follow up cues
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Ending the planning session
Ask permission to record discussion
Summarise points
Check and clarify accuracy
Offer review options/dates
Agree communication plan
Agree storage
Advice on requests for ADRT
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
What is an advance decision to
refuse treatment
Some people may express strong feelings about
treatment they would choose not to have in
particular circumstances. In order to record such
feelings and make it legally binding it is necessary
to make an advance decision to refuse treatment
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Advance Decision to Refuse
Treatment (ADRT)
A decision relating to a specific treatment in specific
circumstances
Can be written or verbal
Must be written, signed and witnessed if it includes a
refusal of life sustaining treatment
Will come into effect only when the individual has lost
capacity to give or refuse consent
Is legally binding
Must be valid and applicable
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
An advance decision is not valid:
If it is withdrawn by the individual who made it
A Lasting Power of Attorney has been created
subsequent to the advance decision
The individual has done anything that is inconsistent
with the advance decision
Does not apply to the specifically stated circumstances
(Consideration may be given to long lapses of time
during which medical treatment advances have been
made.)
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Lasting Power on Attorney
LPA is a legal document which states in writing
who can make decisions for a person if they
lack capacity
Welfare eg accommodation/support
Property eg the need to sell a house
Money eg managing money
Health eg the need for an operation
NB. Not Enduring Power of Attorney
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Mental Capacity Act
Provide empowerment for adults who lack
capacity
Provide protection for adults who lack
capacity and those who care for them
Provide choice - by allowing people to appoint
those they trust to make decisions for them
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
MCA Code of Practice
Provides guidance and information on how the MCA
works in practice
16 chapters
Ch 3.- How should someone be helped to make their
own decision
Ch 5. What does the Act mean when it talks about
best interests
Ch 7. What does the Act say about Lasting Power of
Attorney
Ch 9. What does the Act say about advance decisions
to refuse treatment.
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Things to consider
Has the individual indicated they want to discuss their wishes/preferences?
Are you the right person to do this?
Does the individual have the mental capacity to have this discussion?
Does the individual wish to refuse treatment?
Do you need to involve anyone else?
Does the individual want the discussion recorded?
Who ( with permission) needs to be informed?
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Summary
ACP – patients preferences and wishes
ADRT – decision to refuse specific treatment
MCA- provides a framework for dealing with
mental capacity issues
Best Interests – considers a persons past and
present wishes
LPA – appointed to look after some ones
health and welfare
Court of Protection- deals with all issues
related to MCA
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Hope and ACP
Davison Simpson BMJ
ACP can enhance hope not diminish it
Hope helps determine future goals and provide insight
Information leads to less fear and more control
Helps maintain relationships, preserve normality, reduce feeling of
being a burden, encouraging sense of being in control,
Empowering and enabling
Current practice is ethically and psychologically inadequate
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Notes to support presenter•
Read ‘Advance Care Planning a guide to health and social care staff’
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Slide 2. make additional reference to EoLC Strategy, page 57 point 3.37
Slide 3. make emphasis the fact this is a process not a paper exercise
Slide 4/5. note that although not legally binding an ACP does have legal
standing and must be considered when acting in best interests. Refer to
‘MCA Code of Practice’ chapter 5. on Best Interests.
Slide 6. note that one model does not fit all. Family dynamics requires
skilled handling. Families may be involved but the ACP reflects the patients
wishes not those of the family.
Slide 7/8. note that professionals involved in supporting ACP should have
received some training in both ACP and Mental Capacity Act.
Slide 9. Picture- initial discussions can occur with anyone at any time.
Slide 10. note that discussion does not have to reach a final conclusion it
can be abandoned, re scheduled or left open. Discussions about DNAR or
ADRT only occur if instigated by patient.
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North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust
Notes cont.
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Read ‘Advance Decisions to Refuse Treatment a guide to health and social
care professionals’
Slide 11/12 /13-note ADRT discussions should take place with a
professional who is fully aware of the patients condition and prognosis
Slide 14. read relevant section of MCA Code of Practice
Slide 15. read MCA guide booklets.
Slide 16. all additional information is available in the MCA Code of Practice
Algorithm can be found in the revised version of Advance Care Planning
Guide for health and social care staff (Aug 2008) on End of Life Care
website.
North Hampshire Palliative Care Service working as part of Basingstoke and North Hampshire NHS Foundation Trust