An introduction to advance care planning in practice

Abstract

What are the benefits of advance care planning? Theoretically, the process can facilitate patient autonomy so that patients' future wishes can be carried out once they can no longer decide for themselves, 1 but evidence regarding real benefit is mixed. A controlled trial of the impact of combining improved communication about resuscitation preferences with information on prognosis found no improvement in the quality of end of life care. 12 Other authors have suggested that the wider advance care planning process may also be ineffective in achieving positive outcomes. [13][14][15][16] Conversely, some evidence, including that from a recent small systematic review in patients with dementia and cognitive impairment, 17 points to several possible benefits. These include less aggressive medical care and better quality of life near death, decreased rates of hospital admission, especially of care home residents, and increased rates of hospice admission, 18-20 with those having completed an advance care plan being more likely to receive care that is aligned with their wishes. 21 22 A UK retrospective study of 969 deceased hospice patients found that those who had completed such a plan (57%) spent less time in hospital in their last year of life. It also found that those who died outside of hospital had a lower mean hospital treatment cost than those who died in hospital. 23 Advance care planning is also thought to help families prepare for the death of a loved one, to resolve family conflict, and to help with bereavement. 24 25 For example, a randomised controlled trial of facilitated advance care planning versus usual care in elderly patients in Australia showed that 86% of patients in the intervention arm had their end of life wishes known and respected compared with 30% in the control arm. The same study highlighted a greater level of satisfaction among patients and relatives in the intervention group. Family members of patients in the intervention group who died had lower levels of psychological morbidity. 25 A systematic review published in 2008 examined evidence for improving palliative care at the end of life. It included 41 articles relating to advance care planning and found moderate evidence supporting multicomponent interventions to increase patient uptake of advance directives; however, these studies seldom measured clinically important outcomes. The paper also concluded that

Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life

“…Evidence of its effectiveness is limited and conflicting. 4,137 Some studies have reported benefits. 128,[130][131][132]138,139 These tend to be based on surveys, and to focus on a comparative reduction in days and deaths in hospital and costs associated with care in the last year of life.…”

“…Evidence of the nature, frequency and outcomes of ACP discussions remains limited and frequently conflicting. 4 However, it is apparent that ACP remains uncommon in most areas of professional practice and that both professionals and patients tend to avoid discussions they find difficult. [5][6][7][8][9][10][11][12][13][14] Patient and family responses to ACP and its effect on EOLC outcomes remain poorly understood.…”

“…[172][173][174] Ideally, ACP should be undertaken when people are relatively well, or at least when their condition is stable, with regular review and revision of documented or verbal plans. 4,43 The EOLCS aims for ACP to be initiated when patients are identified as likely to be within the last year of their life. ACP has developed within a cultural and professional ideology combining commitment to the value of individual autonomy and choice and a practice of palliative care promoting a particular vision of 'the good death'.…”

“…128,[130][131][132]138,139 Nevertheless, evidence regarding the effectiveness of ACP is limited and conflicting. 4 The policy is not based on evidence about patients' and the public's understanding and experience of ACP, their preferences for how and when this should be discussed, or their attitudes to death and dying. 175 This study supports findings from previous research that ACP remains uncommon, is often limited to documentation of a few key decisions about CPR and place of death, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent.…”

Hypertension in surgical patients: the role of beta-blockers

“…with great interest. 1 In support of the lack of evidence that reducing blood pressure helps, the authors quote the POISE study, 2 stating that beta-blockers were used to reduce blood pressure preoperatively and the data suggested that it did more harm than good. POISE was not designed to test the effects of reducing blood pressure before surgery in hypertensive patients, but rather to assess whether introducing beta-blockade immediately prior to surgery and continuing it for 30 days reduced the risk of cardiac events in patients at risk of, or with, coronary artery disease, vascular disease, previous stroke, etc.…”