Make advance care plans routine

FUNDING, training and regulation are needed to make advance care planning “core business” across all health care sectors, says a leading advocate of advance care planning.

Associate Professor William Silvester, director of the Respecting Patient Choices program at Victoria’s Austin Hospital, said advance care planning (ACP) and end-of-life care discussions need to be seen as an important part of normal clinical practice.

“It applies just as much to a cardiologist who is looking after someone with end-stage heart failure as it does to a palliative care physician”, he said.

Professor Silvester was commenting on an MJA “Clinical Focus” article outlining strategies to embed ACP into routine clinical care. (1)

The authors, led by Professor Ian Scott, director of internal medicine and clinical epidemiology at Brisbane’s Princess Alexandra Hospital, wrote that ACP could invoke earlier initiation of more appropriate palliative care to reduce the undesired use of invasive interventions, lower the likelihood of inhospital death, prolong life of higher quality and decrease costs.

“In embedding ACP into routine practice, all health care organisations (general practices, hospitals, residential care facilities) need to become ‘conversation ready’; that is, committed to systematically eliciting, documenting and enacting patients’ care preferences”, they wrote.

Professor Silvester said health professionals needed communication skills and adequate time to discuss ACP with patients.

“You can talk about the importance of ACP until you’re blue in the face but unless health professionals are given the communication skills to hold these sensitive discussions, then it doesn’t occur. Unless you give people sufficient time to hold these discussions, it just doesn’t happen.”

Professor Silvester said regulation was also a major driver in the uptake of ACP, with the Australian Council on Healthcare Standards incorporating elements of ACP in hospital standards earlier this year. (2)

“These standards were introduced only a year ago and just simply by hospitals knowing the regulation is coming, we have achieved more attention for advance care planning in the last year than we have in the last 10 years … simply because people know this is what’s expected of them”, said Professor Silvester, who founded the Respecting Patient Choices program in 2002. The program is now established under various names in all Australian states and territories. (3)

Associate Professor Charlie Corke, senior intensive care specialist at Victoria’s Geelong Hospital, welcomed the MJA article. He said it not only emphasised the need for ACP, but also the many challenges in incorporating such planning into routine clinical care.

“Everybody knows that [ACP] needs to be done and recognises its importance, but they’re looking at it as somebody else’s responsibility”, he said.

“It needs a change in perception — that it is a role that’s expected of [clinicians]”, he said. That change has occurred in Geelong, where Professor Corke leads the regional Respecting Patient Choices program.

He said many Geelong GPs now routinely advocate ACP to patients, who were referred to trained facilitators funded by Barwon Health for the discussion and to ratify the forms. The GPs understood the value and “would not step back from it”, he said.

Palliative Care Australia (PCA) chief executive Dr Yvonne Luxford said there had been significant policy progress in ACP, from the support of programs such as Respecting Patient Choices to funding for advance care plans to be uploaded to personally controlled electronic health records.

However, she said consumer and health care professional knowledge of ACP remained “quite minimal”.

“When PCA have surveyed Australians about this issue, we have found that only one in two have even had conversations with their loved ones, let alone with their health professionals”, Dr Luxford said.

She wants education for health care professionals about palliative care and ACP that spans their entire careers.

“Health professionals are used to talking about delicate situations — that comes with the territory — but they’re often not as comfortable talking about death and dying”, she said.

Dr Luxford said the PCA was part of a consortium working on a federally funded project to provide a 24-hour advice line on palliative care and ACP. The program, targeted to the aged care sector, would also be linked into training programs and other palliative care initiatives.

Professor Corke said there was some way to go in arriving at the best approach to this complicated process.

He said systems needed to accommodate to the way people wanted to express their wishes and a one-size-fits-all solution was unlikely to be effective.

1. MJA 2013; 199: 662-666
2. Australian Council on Healthcare Standards 2013; EQuIPNational
3. Advance Care Planning Australia

See Joseph Ting: Final decision about the impact of end-of-life decisions confronting emergency medicine specialists.