Documenting plans for care: advance care directives and the 7-step pathway in the acute care context

Abstract

Background Advance care planning involves the discussion and documentation of an individual’s values and preferences to guide their future healthcare should they lose capacity to make or communicate treatment decisions. Advance care planning can involve the individual’s completion of an Advance Care Directive (ACD), a legislated and common-law instrument which may include appointment of a substitute decision-maker and binding refusals of treatment. In South Australia, ACDs intersect in the acute-care context with the Resuscitation Plan 7-Step Pathway (7-SP), an integrated care plan written for and by clinicians, designed to organise and improve patients’ end-of-life care through the use of structured documentation. Here, we examine the perspectives of healthcare professionals (HCPs) within a hospital setting on the practical integration of ACDs and the 7-SP, exploring the perceived role, function, and value of each as they intersect to guide end-of-life care in an Australian hospital setting. Methods Qualitative data were collected via eight focus groups with a total of 74 HCPs (acute care, and oncology specialists; medical intern; general and emergency nurses; social workers) across two hospitals. Audio recordings were transcribed and thematically analysed. Results HCPs viewed ACDs as a potentially valuable means of promoting patient autonomy, but as rarely completed and poorly integrated into hospital systems. Conversely, the process and documentation of the 7-SP was perceived as providing clarity about clinicians’ responsibilities, and as a well-understood, integrated resource. Participants sometimes exhibited uncertainty around which document takes precedence if both were present. Sometimes, the routinisation of the 7-SP meant it was understood as the ‘only way’ to determine patient wishes and provide optimal end-of-life care. When this occurs, the perceived authority of ACDs, or of patients’ choice not to participate in end-of-life discussions, may be undermined. Conclusions The intersection of ACDs and the 7-SP appears problematic within acute care. Clinicians’ uncertainty as to whether an ACD or 7-SP takes precedence, and when it should do so, suggests a need for further clarity and training on the roles of these documents in guiding clinical practice, the legislative context within which specific documentation is embedded, and the dynamics associated with collaborative decision-making in end-of-life care.

Integrated Care Plan In The Hospital Setting: A Scoping Review

“…Uncertainty surrounding the use of documents like Advance Care Directives (ACDs) and Resuscitation Plan 7-Step Pathway (7-SP) also needs to be addressed in the implementation of integrated care plans (Crawford et al, 2021). Clarity regarding when and under what conditions clinicians should employ these directives is essential for effective end-of-life care planning (Crawford et al, 2021).…”

“…3 Lack of coordination High-risk geriatric disorders, such as functional impairment, fall risk, malnutrition, and various medication-related problems, necessitate coordinated professional treatment for older individuals (Jepma et al, 2021). Uncertainty about when and under what conditions clinicians should use ACDs or 7-SP (Crawford et al, 2021). Lack of integrated care planning, the absence of specialized medical care, and inadequate and interdisciplinary services can all contribute to more excellent patient mortality rates, extended hospital stays, and more expensive healthcare (Wan et al, 2021).…”

“…Lack of regulation The Joint Commission's requirement for a different name scheme may not be sufficient to prevent identifying mistakes among multiple-birth infants in the NICU (Adelman et al, 2019) 5 Lack of knowledge Uncertainty about the roles and value of Advance Care Directives (ACDs) and Resuscitation Plan 7-Step Pathway (7-SP) in guiding end-of-life care in acute care settings (Crawford et al, 2021).…”

“…Clarifying the functions of these documents in directing clinical practice, the legislative environment in which particular paperwork is placed, and the dynamics involved in collaborative decision-making in end-of-life care requires further explanation and training (Crawford et al, 2021).…”

Social and healthcare professionals’ experiences of end‐of‐life care planning and documentation in palliative care

“…Care planning means a process by which professionals, patients and their support network talk over, agree and assess an action plan to achieve the most statistically significant aims (Burt et al, 2014; Gonella et al, 2019; Haavisto et al, 2022; Ho et al, 2022). Advance care planning (ACP) is a special type of care planning (Crawford et al, 2021; Lakin et al, 2021; Wendrich‐van Dael et al, 2021). It endeavours to align patients' end‐of‐life (EOL) care with their wishes and goals (Myers et al, 2018; Steel & Owen, 2020; Sudore et al, 2017).…”