Introduction to Advance Care Planning

by Mark Hughes, MD, MA

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    00:01 In this lecture, we're going to talk about Advanced Care Planning.

    00:04 This is thinking about decisions for the future in advance of when you need to make them.

    00:10 We've talked in previous lectures about goals of care discussions.

    00:14 Those are for more mediate or proximate decisions, and you need to make goals of care discussions in relation to those treatment decisions.

    00:22 Now, we're using advanced care planning to think about these future decisions.

    00:27 So this is a opportunity for prospective plan of care approach to any future decisions.

    00:34 It is a means for a discussion with the patient about their goals and values, while they still have decision making capacity.

    00:41 There may be times in a patient's illness, that they lose the capacity to make their own decisions.

    00:47 So having these conversations in advance, while they're still able to communicate and reason, and process the information is really a good opportunity to say, "Okay, if you need to make these decisions in the future, how would we make them?" There are concerns with advanced care planning of whether it actually represents the authenticity of the patient? Because usually these are in the hypothetical.

    01:10 It's like, if you had such and such condition in the future, would you want X, Y, or Z? So, it's really not a tangible, you know, I have to face this decision right now.

    01:20 It's a hypothetical in the future.

    01:24 You know, when you get there, how would you make the decision? But it's hard for a patient sometimes say, "This is my authentic decision." And maybe they would change their mind in the future, if they had the opportunity.

    01:36 I think there is still a rationale, you know, even despite those limitations, there is a rationale for having advanced care planning.

    01:43 In some instances, it may be necessary to have clear and convincing evidence of what the patient's wishes were, especially with regard to life sustaining treatments.

    01:53 So, if you've had these prior conversations, if you've documented them, either in the medical record, or the patient is documented in what we call an advanced care directive, that provides that evidence of this is representative of the patient's values and wishes.

    02:07 And we should honor those in the future.

    02:10 So the usual elements in advanced care planning are first and foremost that you're going to choose an authorized decision maker.

    02:16 So, this is the person that the patient feels is going to be best representative of their wishes and their values.

    02:23 The term that we use is called durable power of attorney for health care or health care proxy.

    02:28 It could be a family member, it could be a friend, could be anybody that the patient trust, that when the patient loses capacity, that person is going to step in and make decisions for the patient.

    02:41 It's also important advanced care planning to know how that person should make decisions? Does the patient want them to have flexibility in how they make decisions? You know, based on the clinical situation at hand, they're going to rely on the decision maker, this authorized decision maker to make decisions based on you know, their best guess of what should be done? Or is it something that they want, you know, a no flexibility in how that decision maker makes decisions.

    03:07 There's an Advanced Directive document that says this, and you have to sort of follow the letter of the law, what that document says.

    03:13 And just make sure that the authorized decision maker, this proxy, is representing those wishes in that document.

    03:22 The other element of advanced care planning is similar to what we do in goals of care discussions is figuring out what's important in the patient's life.

    03:30 What gives them meaning? Because that can help inform their health values.

    03:34 If we know who the person is, both now and in the future, you know, what's going to be important to them, that can help inform their medical decisions.

    03:43 Another important element that may be relevant to a patient is quantity of life versus quality of life.

    03:50 So are they trying to achieve certain longevity in their life? Or are they going to focus more on quality of life and control of symptoms, and making sure they have a good quality of life.

    04:03 And advanced care planning is also an opportunity to really think through preferences for treatment in particular health conditions.

    04:10 So an Advanced Directive forms, you know, these documents that people complete, often they will ask about, well, how would you make decisions about life sustaining treatment, if you had a terminal illness? If you knew that you were near the end of your life? Or what if you were in a permanent coma? You're never had any opportunity to regain consciousness.

    04:29 How would you want decisions to be made? Or maybe another kind of condition, persistent vegetative state, so you have a sleep wake cycle, but you really have no meaningful interaction with your environment.

    04:40 Different people will make different decisions about artificial nutrition, ventilators, other life sustaining treatments, based on the condition that they have.

    04:52 So thinking that, that might happen in the future to them.

    04:56 How would they think about that now, while they're conscious, uncommunicative, and try to anticipate how those decisions would be made, if they actually did go into one of these conditions.

    05:07 And that then speaks to this idea of particular treatments.

    05:11 You know, the person might say, "I'd never want to be on a ventilator.

    05:14 None under no circumstances.

    05:16 Not just these very serious health conditions, but under any circumstances." So you really want to try to figure out what's important to the person with regard to particular treatments? There may be other wishes that you could also explore with a patient.

    05:28 Would they be wanting to think about organ donation when they die? Would they want an autopsy when they die? Do they have particular funeral wishes? Or would they want certain memorial services to be fulfilled after their death.

    05:44 Those are kind of things that you might talk about in advanced care planning, or at least give the opportunity for the patient to think about that, and talk with their loved ones about these things.

    About the Lecture

    The lecture Introduction to Advance Care Planning by Mark Hughes, MD, MA is from the course Breaking Serious News and Advance Care Planning.

    Included Quiz Questions

    1. It is challenging to authentically answer a hypothetical situation.
    2. It is pointless to predict the future.
    3. Healthcare will change over time.
    4. The future is unknown.
    5. People change their minds about health decisions all the time.
    1. Requesting a full-body scan to look for malignancy
    2. Selecting a healthcare proxy
    3. Discussing how a proxy should make decisions
    4. Determining the patient's healthcare values
    1. Quantity vs. quality of life
    2. Treatment preferences for particular conditions
    3. Selection of a healthcare proxy
    4. Alternative medications to aspirin
    5. Duration of MRI pelvis

    Author of lecture Introduction to Advance Care Planning

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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