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HEALTH professionals increasingly have to deal with end-of-life issues as more people with chronic diseases live longer.
But it is a topic that can be mired in complex legal and ethical issues, which is why the Australian Health Ministers’ Advisory Council convened a working group to develop A National Framework for Advance Care Directives. It’s an important reference tool for health professionals who need to consider and respond to issues regarding advance care directives (ACDs).
An ACD reflects personal views and is intended to ensure that, even if a person loses decision-making capacity, their preferences and directions regarding medical treatment can be respected and honoured. An ACD allows adults to specify situations in which they would want to either provide or refuse consent for future treatment.
The increasing use of ACDs has led to legislative changes in some states, and the ensuing public debate has reinforced the expectation that competent adults have a right to personal autonomy.
The framework uses clear language with descriptive case study examples of the application of ACDs. The examples are illuminating, offering a useful reference point for doctors and health professionals.
The case studies, such as the one of a woman with advanced stage breast cancer, are intended to prompt clinician self-reflection and encourage doctors to have conversations with their patients and their families about planning for future care.
Care that promotes dignity and autonomy can reduce the suffering of both the individual and their family. In cases where decisions about treatments have to be made and options explored, the existence of an ACD can make discussion with family or significant others much less stressful and distressing.
If a substitute decisionmaker has been appointed, then they must be consulted about the person’s preferences for treatment or care. However, treating doctors will continue to consider the clinical appropriateness of treatment, and a decision regarding whether a treatment is medically futile will still be required.
There is a clear distinction between an ACD written by a patient and a clinical care plan written by health care professionals for that patient.
ACDs address a broader range of health and personal matters. They can record values, goals and lifestyle preferences in the absence of any impending (or actual) need for medical care.
Clinical care plans are more prescriptive and are prepared in conjunction with the clinician and patient or substitute decisionmaker to give directions regarding the care to be delivered during admission to hospital. They involve the physician in an information exchange that can assist the responsible person to make choices that are appropriate and are most likely to apply to the patient’s current health conditions.
The clinical care plan should consistently reflect the patient’s wishes as expressed in the ACD and is an important document for communication between clinicians, to ensure the care given is consistent and that agreed plans are followed when other clinicians are responsible for the patient.
The framework document also includes: a code for ethical practice that reflects the best practice standards for the development and use of ACDs; a justification for the use of nationally consistent terminology; information on substituted judgement; and a decision-making pathway. An appendix provides information regarding the current state of play in each jurisdiction.
The document addresses the challenges posed by divergent laws and the concerns expressed about the use and application of ACDs for clinicians, other health professionals, policymakers and legislators.
Dr Simon Towler is an intensive care physician and is the WA Chief Medical Officer. He chaired the National Advanced Care Directives Working Group, advising the Australian Health Ministers’ Conference.
Posted 16 January 2012