Advance care planning

As with all forms of care planning, advance care planning (ACP) exists to provide a blueprint for the care of an individual based on an assessment of their needs as well as what they want and, when appropriate, the views of those closest to them. The main difference between care planning and ACP is that advance care planning refers to the care of the individual around the end of their life and the plan may not apply at the time of the assessment.

Perhaps the most commonly used consensus statement which refers to ACP states:

As with all care planning, the Nursing and Midwifery Council (2018) expect nurses to ensure ACP is undertaken in a person-centred way putting the patient’s interests first. ACP is indicated for any individual who wants to record their wishes and preferences regarding the type of care they receive at the end of their life, as well as where that care is delivered and potentially by who.

Recording one’s wishes for the end-of-life is more important than some nurses realise, since people have widely differing views as to their priorities. For example, some people will want to have every opportunity to gain additional days of life and are willing to be subjected to all manner of treatments and interventions to attain this, while other people want a peaceful experience of the end of life with friends and family present and minimal medical and nursing intervention. Such decision making is important as

Advance care planning might take into account various elements including:

• Advance statements
• Advance Decision to Refuse Treatment
• Lasting Power of Attorney
• Recommended Summary Plan for Emergency Care and Treatment
• Do Not Attempt Cardiopulmonary Resuscitation

In gathering what they need to undertake ACP, the nurse will need to take account of any of the above documents the patient may have already completed as well as any they may want to complete. Notably research suggests the use of educational materials is helpful in facilitating ACP conversations in a variety of setting, e.g. video decision support tool in advanced heart failure (El-Jawahri et al, 2016), vignettes in cancer care (Michael et al, 2016) and multimedia, interactive, computer-based decision aid among a variety of older people (Green and Levi, 2009).

Advance care planning does not therefore rely on a prescribed set of documentation, nor a single strategy, although the approach to undertaking does require some structure and must be documented (National Institute for Health and Care Excellence, 2020). Advance Care Planning is not something the nurse can rush into doing with a patient. As Zwakman et al (2020) identify, while paperwork identifies people’s wishes, understanding why patients choose what they do requires the nurse to have meaningful conversations with them.

While there is no agreement about how an ACP conversation should be started nor who should undertake it (Kononovas and McGee, 2017), it does need to be undertaken once the patient understands they have a prognosis which means they may lose the ability to exercise choices over their care especially around the end-of-life.

The GSF (2018) helpfully describes a structure the nurse might apply to the process of ACP. The

Failing to undertake ACP may mean patients end-of-life care is not what it should be and does not reflect their wishes. Poorly undertaken ACP which is not considered and undertaken empathetically risks not capturing what the person truly wishes. As well as having an impact on the patient and their care, these potential failings also risk causing upset to friends and relatives, who may also wonder what is happening if they are not involved in the process (although this is not always appropriate).

Failing to undertake ACP until the death of an individual is imminent may mean that the process is hurried and fails to capture what is needed, while for patients who are unaware of, or fail to understand, they are dying may see the process as irrelevant (Guo et al, 2010).

Nurses who are not familiar with ACP should either undertake training and develop competence in the process, assuming they will use it frequently, or seek out other care professionals to undertake, or to support them in undertaking the process, who are familiar (National End of Life Care Programme /National Council for Palliative Care, 2013).

References

Beauchamp T, Childress J. Principles of Biomedical Ethics (7^th edn.). Oxford: Oxford University Press; 2013

El-Jawahri A, Paasche-Orlow MK, Matlock D et al. Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With Advanced Heart Failure. Circulation. 2016;134:52–60. https://doi.org/10.1161/CIRCULATIONAHA.116.021937.

Ellis P. Understanding Ethics for Nursing Students (2^nd edn.). London; Sage; 2020

Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017; 356:j813

Gold Standard Framework.  Advance care Planning. 2018. Available at: http://www.goldstandardsframework.org.uk/advance-care-planning.  (Accessed 17 May 2022).

Green MJ, Levi BH. Development of an interactive computer program for advance care planning. Health Expectations. 2009;12:60-69. https://doi.org/10.1111/j.1369-7625.2008.00517.x.

Guo Y, Palmer JL, Bianty J, Konzen B, Shin K, Breura E. Advance directives and do-not-resuscitate orders in patients with cancer with metastatic spinal cord compression: advanced care planning implications. J Pall Med. 2010;13(5): 513-517.

Kononovas K, McGee A The benefits and