[HD 202]-E03-T14-Advance Care Planning (Compressed)

• Advance Care Planning is about human development focusing on physical and psychosocial aspects

Illness Trajectory

• This explains the course of a life-threatening condition from diagnosis to death
• Point A signifies the diagnosis, use in advance care planning
• Initiate treatment at point B
• Deterioration occurs from point B to C
• Admission to the hopital at point C
• From C to D there is an improvement after the treatment, although function is lower than normal
• Further decline at point D to E
• At point F improvement occurs although functional capacity is decreased
• Point F to G marks further deterioration ultimately leading to death

Palliative Care

• Improves quality of life for patients and families facing life-threatening illnesses (physical, psychological, social, spiritual)
• It enhances the well-being of caregivers through holistic care
• Encompasses care for patients with active, progressive, far-advanced diseases, focusing on relief and quality of life
• Palliative care is provided in neonatal units, pediatric services, acute care hospitals and in-patient wards
• It is also delivered in intensive/critical care units, general practices, residential and community aged care services
• Home care settings, workplaces, general community locations, and RHU/Health Care Centers are also locations for palliative care

When to Refer for Palliative Care

• Referral can occur anytime from diagnosis to deterioration, treatment failure, or lack of improvement
• Signs of distress such as pain or shortness of breath justify a referral
• Referral isn't solely for the terminally ill
• Late referral is when the patient is already exhibiting signs of dying

Triggers for End-of-Life (EOL) Communication

• For adults with cancer, prognosis such as "Would you be surprised if this patient died in the next year?"
• This presents the change to discuss advance care planning
• For disease-based criteria, all patients with advanced non-small cell lung cancer, nonresectable pancreatic cancer, and/or glioblastoma or patients older than 70 years with acute myelogenous leukemia are candidates
• Third-line chemotherapy serves as a treatment-based identification

Adults with COPD

• Lack of further treatment options, functional decline, ongoing symptom exacerbation, ongoing oxygen requirements, multiple hospitalizations or complex needs indicate need for intervention

Adults with Heart Failure

• Increased symptoms, reduced function, hospitalizations, progressive increase in diuretic need, hypotension, azotemia, initiation of inotrope therapy, not a candidate for advanced cardiac therapies, or first or recurrent implantable cardioverter-defibrillator shock are triggers

General Triggers

• Being over 80 and hospitalized or based on prognosis

Advance Care Planning (ACP)

• Learning about the types of decisions that might need to be made and considering those decisions ahead of time is key
• It depends on patient values, wishes on how they want to be cared for during their "end-of-life care"
• Preferences and treatment options, and also legalities are needed

Advance Directives (AD)

• Family involvement is important

• Express values and desires related to "end-of-life care"

• This conversation is put down in a document referred to as:

  • Living will (layman term)
  • Advance Directive (AD) (medical term)

• In various states the legal instrument is entitled "Directive to Physicians" Natural Death Act

• It is a "Living document" which can be adjusted

Why Advance Directives Are Important

• Needed because of a serious illness that keeps you from making a medical decision for yourself
• Doctors are informed about the type of care

Kinds of Advance Directives

• Physician Orders for Life Sustaining Treatment (POLST)
• Medical Orders for Life Sustaining Treatment (MOLST)
• Already being used in one institution in the Philippines
• Called "Allow a Natural Death" Form in some hospitals in the Philippines

Context for Writing a Living Will

• End of life stage with chronic condition, progressive terminal illness, irreversible damage, or vegetative state
• Considerations include the use of equipment (dialysis machines or ventilators):
  • Dialysis until death and/or if there is no improvement, switch to full comfort care;
  • Aggressiveness of treatment for breathing difficulties;
  • CPR despite progressive medical condition

Important Considerations

• Explain patient's condition/choices
• "Do not resuscitate" (DNR) orders (instructions NOT to use CPR if breathing or heartbeat stops)
• Fluid/food intake (IV/tube feeding), and symptom treatment

Example Scenario

• Role of physicians in motivating patients to participate
• This can avoid difficult situations for surrogate decision makers who don't know patient's wishes
• It can ensure the person is receiving person-centered care

How to Initiate ACP in Regular Consultation

• Identify a patient for ACP and introduce the concept
• Explore understanding of ACP by asking patient what they know

Five Wishes

• What person you want to make healthcare decisions
• Type of treatment
• Comfort level
• Treat you
• What you want loved ones to know

Who should use Five Wishes?

• Anyone 18 or older and works for Lawyers, doctors, hospitals and hospices, faith communities, employers, and retiree groups

How Can Five Wishes Help a Patient's Family?

• Informs how the family can treat a patient
• Talk with the family and friends, and can be guided by experts

Must Know for the Exam

• Daughter from California Syndrome
• Five Wishes can serve as a good document to show to this person

Details of the Five Wishes

• Wish 1: Selecting the right person to be patient's healthcare proxy (Substitute Decision Maker or Surrogate Decision Maker)

  • Someone who knows the patient best
  • Someone who will stand up for the patient so that their wishes are followed

• Wish 2: Preferences for medical treatment (invasive, non-invasive, selected, or comfort-focused)

Additional Pointers

• Wish 3: How comfortable I want to be
• Wish 4: I want people to treat me
• Active listening skills
• Medical recommendations

Q&A

• Involve the parents
• Multidisciplinary approach

Elderly Patient

• No written advance directive
• Families often have arguments about this
• Honor patient's wishes

Additional Information from 2027 Trans

• Death is unavoidable
• ACP essential
• Goal to be proactive
• Involves life planning