Advance care planning influences patient's wishes for future medical treatments, and the nomination of surrogates

Abstract

Background Advance care planning (ACP) assists patients to document their future medical treatment wishes and to appoint a surrogate. It is assumed that discussion with patients about their medical conditions, treatment and prognosis will influence and potentially change these decisions. Aim To assess the impact of ACP on decision-making regarding: (1) Patient wishes regarding cardiopulmonary resuscitation (CPR), and life-prolonging treatment (LPT); (2) Whether they have and correctly report having a surrogate. Methods In our previous study (BMJ 2010) of 154 patients allocated to ACP intervention, 125 completed ACP and108 expressed wishes regarding CPR and LPT. At study enrolment all patients were asked whether they already had any wishes on end-of-life care including CPR and LPT, and whether they already had a surrogate. Results LPT, and CPR (%) Decisions Yes Yes- DOO* No Delegate# Don't know CPR Pre-ACP 25 19 43 0 13 Post-ACP 4 30 49 17 0 LPT Pre-ACP 62 7 29 0 2 Post-ACP 3 36 36 23 2 *depending on outcome #delegating decision-making to surrogate/doctor. Nomination of surrogate After ACP 58 patients had a surrogate, 18 of which were pre-existing. At enrolment only 10 of these correctly identified they had a surrogate, 6 said they did not and 2 didn't know. Conclusion Following ACP many patients change their wishes regarding CPR, and LPT, often to less aggressive treatments and often choose to delegate decision making to others. ACP also assists patients to nominate and understand the important role of surrogates.

Failing to Plan is Planning to Fail: Advance Care Planning for People Nearing the End of Life

“…Peter Saul, Intensive Care Unit Consultant from John Hunter Hospital, Australia, presented stark figures regarding deaths in acute settings in New South Wales, Australia, where there was a 60-70% chance of death in an acute setting, with an average of eight admissions and two emergency department attendances in the last year of life [6]. Karen Detering took the issue of surrogate decision-making further, highlighting misunderstandings regarding differences between different powers of attorney [7]. Legal frameworks for appointment of surrogates vary significantly across the international community.…”