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.