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| Guidelines on Advance Care Planning - when our patients lose capacity |
| Email your comments In April 2007, the Mental Capacity Act came into force. The Act, in combination with NHS initiatives to improve end of life care generally, means that we are likely to seen an increase in advance care planning. Advance care planning has been defined as a process of discussion between an individual, their care providers, and often those close to them, about future care. The discussion may lead to:
All or any of these can help inform care providers should the individual lose capacity. These terms supersede previous phrases such as ‘living wills’ and ‘advance directives’. It is likely that geriatricians will be seeing more and more patients with advance decisions and/or advance statements. Whilst the British Geriatrics Society (BGS) has acknowledged that advance care planning has an important role in helping determine best interests when an individual no longer has capacity, there are some concerns about the evidence base underpinning their use. The current literature is dominated by the North American experience – and it is not clear how well this evidence translates to the UK. There are many known unknowns, to paraphrase Donald Rumsfeld, including what are the optimal settings in which to introduce advance decision discussions – hospital or community, before or after illness? What will be the impact of Lasting Powers of Attorney? Will advance decisions lead to the denial of appropriate care? Given that geriatricians frequently care for individuals likely to lose capacity and in whom end of life discussions are relevant, the BGS Clinical Practice and Effectiveness Committee sought to take the lead on the development of a set of robust evidence based guidelines for clinicians on advance decisions and advance statements. Initially a BGS venture, these evolved into national guidelines involving the RCP, Age Concern, the Alzheimer’s Society, the Royal College of Nursing, the Royal College of General Practitioners and the Faculty of Old Age Psychiatry. After two years of development the guidelines (Conroy S, Fade P, Fraser A, Schiff R. Advance care planning: concise evidence-based guidelines. Concise Guidance to Good Practice series, No 12. London: RCP, 2009) have now been published in concise form. Click here for a downloadable version. The aim of the guideline is to inform health and social care professionals on how best to manage advance care planning (ACP) in clinical practice. The guideline contains a number of recommendations, such as training for and implementation of ACP, when and with whom to consider having ACP discussions, the context and content of discussions, preparing ACP documents and cognitive impairment. The key recommendations are that discussions should be led sensitively, being aware that many people do not wish to have such discussions thrust upon them, and that the professional leading the discussion has the appropriate knowledge and training to advise the older person. One specific area of controversy related to advance care planning is the use of advance decisions to refuse treatment (ADRTs). Although these decisions will only be used in a minority of people (no more than 10%), they can cause considerable uncertainty for health professionals faced with patients who have lost capacity but have prepared a draft statement. Some of the issues are discussed in the guidelines, but more details on ADRTs can be found at www.adrt.nhs.uk The document is primarily aimed at professionals in England and Wales (there are legal differences in the devolved nations) and will be relevant to all doctors involved in ACP, especially geriatricians, psychiatrists, general practitioners, general physicians and acute medicine specialists. We hope that the guidance will be of use to BGS members and welcome your feedback as to whether or not such guidance is useful. Simon Conroy BGS Newsletter, March 2009 |