Member Services
- Text Decrease
- Text Increase
- Print Page
Advance Care Planning: finding out what patients want
Dr William Silvester
How often could we as doctors have greater certainty that patients are receiving treatment that they actually want? Associate Professor William Silvester, Director of the Respecting Patient Choices Program at the Austin Hospital, and Intensive Care Specialist, offers some thoughts.
The easiest way to find out is to simply talk to our patients about what they would want us to do if they became seriously ill and, as a result, lose the ability to communicate their wishes. This is what we call Advance Care Planning. It is supported by the ethical principles of autonomy (including informed consent), beneficence (doing good), non-maleficence (do no harm) and dignity (including the prevention of suffering).
Although people often get caught up in the legalities, the forms and paper-work, in fact the most important element is the discussion that doctors have with their patient and, if possible, their patient’s family.
So what do we talk about with our patients? First of all we make sure they have a good understanding of their state of health, their illnesses and their treatment options. Then we also find out what their goals and values in life are and how these would apply to any current or future decisions they may face. For example, if your patient has severe emphysema that now severely restricts his activities, would he want to be put onto a ventilator if it becomes much worse? Or, if a patient has a stroke that leaves her unable to speak or eat and needs admission to a nursing home, would she prefer to be just kept comfortable when taken to the hospital by ambulance?
Recently I reviewed a patient on the ward at the Austin Hospital who had been discharged from the ICU the week before. She was 76 and had been admitted to the ICU for treatment of pneumonia and heart failure after fixation of a fractured hip. She also had mild renal impairment and was on maximal treatment for her heart failure. She told me she did not get out of the house much before the hip fracture.
She also told me that although she was grateful for all the care that she had received, if her heart failure worsened or if she had another bout of pneumonia, she did not want to go back to intensive care and did not want “anyone jumping on my chest”.
There were a few tears through this brief but deeply personal discussion and it was clear that it was important that her husband, a retired professor, was sitting there holding her hand and listening intently to what she had to say. In just five minutes I assisted her to appoint her husband as her Medical Enduring Power of Attorney and to put in writing, in an Advance Care Plan, what she had stated so clearly. She said “I want to write this down doctor because you may not be here next time something happens to me and I don’t want them to get it wrong”.
All too often our patients’ wishes are considered too late to make a difference. Then they end up on a conveyor belt of investigations and interventions that they would never have wanted, if only we had asked them. Research shows that patients, and the public, expect us to bring this up. If we don’t then the conversation does not occur.
Does this mean that we blindly follow whatever our patients, or their families, request? The answer is no. We still need to use our knowledge and experience to make clinical decisions.
So what is our common law duty of care as doctors? It is to take reasonable steps (as other reasonable doctors would) to save or prolong life or act in the patient’s best interests.
What this emphasises is that, as doctors, we are not obliged to provide treatment that is of no benefit (and may be harmful), even if that treatment is demanded by the patient’s family or, indeed, the patient. A thoracic surgeon would not agree to do a pneumonectomy simply because a patient expressed an unsubstantiated concern about a “shadow on the lung”. A cardiac surgeon would not do a valve replacement on someone with end-stage heart failure.
Therefore, I would ask, why would a doctor promise to provide CPR to an elderly person with severe heart and kidney disease, who would not respond to CPR in a cardiac arrest, or, at best, would end up with significant hypoxic brain damage?
Legally, you are not required to obtain consent from the competent patient or the family of a non-competent patient in order to put a limitation of treatment in place, but it is important to communicate with the patient or family.
Patients have a right to refuse any treatment, even if this will ultimately lead to death. For example, a patient may turn down surgery or chemotherapy for a newly diagnosed cancer or a patient with end-stage kidney failure may turn down dialysis.
Therefore, our role as doctors is to identify which treatments are medically indicated and offer these to patients or their substitute decision maker, and it is the patient’s or the substitute decision maker’s role to choose from the treatments on offer.
These discussions with patients or families are not always easy but they are important and are best held in the “cool light of day” when there is time, rather than when a decision needs to be made urgently or under stressful emotional circumstances.
The aim of the Respecting Patient Choices Program is to give every patient the opportunity to tell us what they want and then to ensure that health professionals act in the patient’s best interests, including respecting their wishes.
For further information, brochures or advance care planning documents, please visit the Respecting Patient Choices website.
If you are a GP a learning package called “Advance care planning for GPs” is available on the RACGP GP e-learning website.
This article was published in the May 2011 edition of vicdoc. The views expressed are those of the author and may not reflect necessarily the policy of AMA (Victoria) Ltd.
Victorian Medical Directory
Quick Reference Links
Networks
Preferred Providers
Next
Prev