Advance Care Planning to Improve End of Life Care
This clinical information sheet has been developed to assist RACF staff, medical practitioners and relevant professionals involved in the management of residential aged care patients to discuss patient choices for end of life care, and to develop and use Advance Care Plans with their residential aged care patients.
It covers:
About Advance Care Planning Steps to Develop an Advance Care Plan Using an Advance Care Plan Sources of Information Reference Cards:
GP steps to advance care planning
Assessing a patient’s legal capacity
Advance care planning discussion guide
Resident information and documentation for advance care planning
Resident information and documentation for advance care planning - for a resident who cannot consent
Fact Sheets:
Enduring Power of Attorney (Medical Treatment)
The ‘Person Responsible’
Refusal of Medical Treatment
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Advance Care Planning
Advance Care Planning is a process enabling a patient to make decisions about his or her future health care in consultation with their health care providers, family members and other important people in their lives. Based on the ethical principle of patient autonomy and the legal doctrine of patient consent, Advance Care Planning helps to ensure that patient choice is respected if the patient becomes incapable of participating in treatment decisions.
Conflicts frequently arise in medical decision-making, and there may be a discrepancy between a patient’s end-of-life care and their wishes for care [1]. To address this problem, attempts in several countries have been made to introduce an Advance Care Plan also called an advance directive or living will.
In Victoria, advance care planning is based on powers enabled by the Medical Treatment Act (1988) and encourages patients to appoint a Medical Enduring Power of Attorney (MEPOA) called the ‘agent’. Advance Care Planning involves conversations between the patient, their agent and their family/loved ones about their values, beliefs and goals in life, and, in light of their current health status, what medical treatments they would and would not want in the future. Several versions of Advance Care Plan documentation have been developed by health care organisations in Victoria. The most widely known program currently is Respecting Patient Choices, developed by Austin Health. [2]
Respecting Patient Choices Program
The Respecting Patient Choices Program aims to: [2]
Promote a patient’s understanding about their health and the treatment options available to them Assist them to document their wishes and preferences about future medical treatment, particularly end of life treatment, in an Advance Care Plan.
The Respecting Patient Choices Program is based on a program titled Respecting Choices that was successfully implemented in all hospitals, clinics, nursing homes and hospices in the La Crosse community, Wisconsin, USA [3]. Results of a retrospective study of 540 eligible adult decedents showed 85% of patients had a written advance directive, and 95% of these were in the decedent’s medical record. Almost all advance directives requested that treatment be foregone as death neared. All decedents in the study were mentally capable of determining preferences in the 10 years prior to death, but only 43% were capable at the time end of life decisions were made. Treatment was forgone in 98% of deaths in ways consistent with the advance directive – CPR 100%, hospitalisation 32%, feeding tube 18%, ventilation 17%, and antibiotics 7%. Nearly 50% died in long-term facilities, slightly more than one third died in hospital and 14% died at home [3]. Three key success factors were: [2]
Using the completion of patient advance request forms to catalyse discussion between the patient, next of kin and hospitalstaff regarding the patient‘s end of life care Educating medical and other key staff about the program and its relevance to daily clinical practice Placing a plastic ‘green sleeve’ containing the patient’s Advance Directive in the patient’s medical records. This ensured the patient advance request form went with the patient and had maximal impact on end of life care when needed.
In 2002-3, the Austin Hospital adapted the Respecting Choices program to address similar issues in end of life care, and produced the Respecting Patient Choices Program. Evaluation showed similar success rates to the Wisconsin program [2]. Patients indicated they wanted to discuss their current health condition and future medical options, and expected health professionals to raise the subject with them [4]. Doctors, nurses and allied health staff reported greater satisfaction knowing they were delivering care that was consistent with patient wishes [4].
Currently the Respecting Patient Choices Program is being rolled out as a pilot program in several organisations in Victoria and interstate.
GP role in advance care planning
A GP may be the key person to facilitate the process with some patients, their relatives and RACF staff. For other patients, the GP may be asked to support the process when facilitated by someone else, such as a Respecting Patient Choices Consultant, RACF staff, or health professional from an aged care service, palliative care service or hospital. The specific roles of the GP in supporting advance care planning include:
Providing the patient with information regarding their current health status, prognosis and future treatment options Witnessing the Medical Enduring Power Of Attorney form Completing a Refusal of Treatment Certificate where appropriate Applying patient wishes to medical plans, including Not For Resuscitation documentation.
The principles and documents in this Clinical Information Sheet are adapted from the Respecting Patient Choices Program and the Office of the Public Advocate in Victoria, to inform and improve discussions that GPs may have with their patients approaching end of life care, particularly as part of medical care planning for residential aged care patients. The steps to develop an Advance Care Plan, outlined below comply with Victorian legislation.
See the Reference Card: GP Steps to Advance Care Planning, for a summary of steps in making and using an Advance Care Plan, and assessing a patient’s legal capacity to appoint a Medical Enduring Power of Attorney and make an Advance Care Plan.
Steps to Develop an Advance Care Plan
Patients have the right to make decisions about their health care, now and for the future. Medical treatment should only be given with full informed consent and patients have the right to consent to or refuse treatment. If, in the future, a patient becomes unable to express his or her choices for treatment, those providing medical and personal care and the patient’s family/loved ones may not know the patient’s wishes. Advance care planning provides the opportunity to discuss and record a patient’s care and treatment choices in advance.
The Advance Care Plan only comes into use when the person is no longer able to communicate his/her wishes.
A person who has legal capacity can make their treatment wishes known in advance through using any or all of the following documents:
A person who does not have legal capacity can make their treatment wishes known in advance through the following documents:
Advance Care Plan – for a person who does not have legal capacity to make medical decisions form completed by an existing MEPOA/’agent’ or the ‘Person Responsible’ Refusal of Treatment Certificate – Agent or Guardian of Incompetent Person.
The GP can facilitate or participate in advance care planning through the steps outlined in the box.
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GP steps to Advance Care Planning
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Step 1. Incorporate Advance Care Planning as part of routine care
If initiating:
Offer/initiate Advance Care Planning when doing a comprehensive medical assessment or medical care plan, Reassure the patient that Advance Care Planning is part of routine care, Explain the rationale and steps for Advance Care Planning, and Suggest that the family/agent be involved in future consultations about the patient’s wishes
Step 2. Assess capacity of patient
To appoint a Medical Enduring Power of Attorney (MEPOA). To complete an Advance Care Plan. Document assessment of capacity.
(Either) Where patient has legal capacity, witness the Enduring Power of Attorney (Medical Treatment) form
Check and witness that the:
Patient has legal capacity, Agent/s is/are appropriate and agree, and Form has been completed correctly.
(or) Step 3b: Where patient does not have legal capacity to appoint a MEPOA - identify the ‘Person Responsible’
Step 4. Support discussion and Advance Care Plan
Discuss patient wishes with patient, family/agent/’person responsible’, and RACF staff, Provide information on medical conditions, benefits and burdens of treatment, and Review Advance Care Plan or Advance Care Plan – for person who does not have legal capacity to make medical decisions
Step 5. Complete Refusal of Treatment Certificate (RTC) where appropriate
Step 6. Review the Advance Care Plan
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Step 1: Incorporate advance care planning as part of routine care
When Advance Care Planning discussions are held with the patient, the agent/person responsible and health care providers, treatment choices are more likely to be understood and enacted when needed. If initiated early, while patients are still capable, these conversations can provide the necessary information and the time to assist patients to consider the information in the context of their values and goals. If these types of discussions occur late in a person’s illness, s/he is more likely to not be capable of participating in decision-making, and decisions may be more difficult for RACF staff, families and doctors to make.
The advance care planning process usually involves several hours of discussions plus documentation of a patient’s wishes.
The elements of advance care planning are considered to be necessary medical treatment. GPs can claim MBS remuneration for their contribution as part of patient consultations, case conferences, a comprehensive medical assessment and contribution to a resident’s care plan. (Refer to Using MBS Items in section 3
Opportunities to initiate advance care planning may occur:
When doing a Comprehensive Medical Assessment of a new resident During a routine patient consultation Through discussion with RACF staff or service that provides advance care planning When doing medical care planning.
When initiating advance care planning:
Explain the rationale for Advance Care Planning Reassure the patient that Advance Care Planning is part of routine care Suggest that the family/agent be involved in future consultations about patient’s wishes and care Offer written patient information, fact sheets and documentation.
Information for residents and their relatives are included here. The Reference Card: Resident information and documentation for advance care planning is appropriate for residents who have the capacity to make decisions about their own medical care. The Reference Card: Resident information and documentation for advance care planning - for a resident who cannot consent is appropriate for residents who do not have the legal capacity to make decisions about their own medical care.
Step 2: Assess capacity of patient
In order to complete his/her own Advance Care Plan, a patient must have decision-making capacity. There are many tools to assess a patient’s capacity, however, there is no validated tool currently in use in Australia.
To assist in this assessment the GP may ask the patient questions to ensure they understand that:
Advance Care Planning includes future choices, The Advance Care Plan is only used when a person is incapable of making decisions for him/herself, Advance care planning includes selection of a MEPOA &/or specific medical preferences, and Choices can be changed at any time.
It is advisable that the GP review the patient’s capacity throughout the Advance Care Planning process, taking the opportunity provided by the patient reflecting on decisions over a number of visits. Sometimes the GP may also need to judge whether a formal assessment of capacity is required, eg by a neuropsychologist.
See the Reference Card: Assessing a Patient’s Legal Capacity for an example of documenting a residents capacity.
Capacity to appoint an agent
If a patient understands the nature and effect of a MEPOA, the individual has the capacity to appoint another person to be their MEPOA (called an agent). The agent can then make future medical decisions on behalf of the person if they become incapable of making decisions for themselves.
The nature and effect of a MEPOA can be explained to the patient using the Enduring Power of Attorney (Medical Treatment) Fact Sheet from the Office of the Public Advocate.
Understanding the nature and effect of a MEPOA includes understanding (and stating):
The powers of the agent, That the power will operate if the patient loses the ability to make medical treatment decisions, That once the power is exercisable, the MEPOA has the ability to consent to treatments and also refuse treatments being offered on the patient’s behalf, That the patient may revoke the MEPOA at any time while the patient is still capable of making an MEPOA, and Once the patient loses capacity s/he will not be able to supervise the use of the powers.
Capacity to complete an Advance Care Plan
When assessing a patient’s capacity to complete an Advance Care Plan, the GP should consider if the individual understands the following:
The general nature, consequences, broad benefits and burdens of what is being discussed, They are able to take responsibility for making a choice, and They are able to make decisions in the context of their current medical condition.
For a patient who does not have legal capacity
If a patient does not have the legal capacity to sign a MEPOA, the ‘person responsible’, eg, their next of kin, or an appointed guardian can make medical decisions for them (Guardianship and Administration Act, Vic 1986).
The nature and effect of the ‘person responsible’ can be explained to the patient using The ‘Person Responsible’Fact Sheet from the Office of the Public Advocate.
If the GP does not believe the patient has capacity to complete the Advance Care Plan independently, it is recommended that the family assist the patient to complete the Advance Care Plan – for a person who does not have legal capacity to make medical decisions and all should be encouraged to sign the document.
Step 3a: Witness the Medical Enduring Power Of Attorney form
The Enduring Power of Attorney (Medical Treatment) is a legal document that enables a patient to nominate another person to make medical treatment decisions on his or her behalf. The person, referred to as the MEPOA or agent, can make health care decisions on a patient’s behalf only if the patient becomes medically assessed as incapable of deciding on or unable to communicate their treatment choices.
The patient must sign the MEPOA form in the presence of two witnesses. One witness must be authorised to sign statutory declarations. By law the nominated agent or alternate agent cannot also be a witness to the MEPOA form. In witnessing the signing of the form the witnesses must declare that they believe the patient signing the MEPOA form is of sound mind and has the capacity to make the decision.
In Victoria, those who can sign statutory declarations include a justice of the peace or a bail justice, a barrister or solicitor of the Supreme Court, a registered medical practitioner, a dentist, a pharmacist, or a minister of religion authorised to celebrate marriages.
It is recommended that the patient’s GP witness the Medical Enduring Power of Attorney (MEPOA) form, as this will involve the GP in the Advance Care Planning process, and facilitate use of the Advance Care Plan in future medical care.
If requested to witness the Medical Enduring Power of Attorney Document, the GP should check that the:
Patient has legal capacity Agent/s is/are appropriate Form has been completed correctly and is therefore legally valid, with
- One agent, or an agent and an alternate agent
- Two witnesses, including a person qualified to sign a Statutory Declaration (preferably the patient’s GP).
Selecting an Agent
To appoint a MEPOA or agent the patient must be over 18 years of age, able to understand the nature and effect of the power of attorney, and capable of choosing an agent.
A patient may only select an agent who is over 18 years of age and has the capacity to make decisions on the patient’s behalf.
A patient may also choose to nominate an alternate agent who will only make decisions if the agent is unavailable, or becomes incapable of making decisions. The alternate agent can only make decisions for the patient if they sign a statutory declaration stating that the agent is either dead, incompetent or cannot be contacted.
Once nominated, the agent and/or alternate agent have the power to:
Agree to medical treatment on the patient’s behalf, and Refuse medical treatment on the patient’s behalf if the treatment would cause the patient unreasonable distress or if the agent believes on reasonable grounds that the patient would not wish the treatment to continue.
The agent does not have the power to make non-medical decisions, nor does he or she have the power to refuse palliative care.
When selecting someone to be an agent, it is important to choose someone who is:
Trustworthy and knows the patient well. Willing to respect the patient’s views and values. Able to make decisions under circumstances that may be difficult or stressful.
Often a family member is a good choice as an agent, but not always. The agent should be someone who will closely follow the patient’s choices and advocate on the patient’s behalf.
It is important that the patient discusses his or her wishes with the agent, family and friends. This information is designed to assist the agent to make decisions on the patient’s behalf, if he or she is unable to do so alone.
Step 3b: Identify who is the ‘person responsible’
If a patient does not have the legal capacity to appoint a MEPOA, or has not already appointed a MEPOA, responsibility for their medical decision-making defaults to the ‘person responsible’ (often their next of kin, or an appointed guardian; Refer to Fact Sheet: ‘The Person Responsible’ for the ‘person responsible’ list under Victorian law). In this case, it is recommended that the GP identify the ‘person responsible’ from this list so that they can then be contacted to discuss the patient’s wishes with the family and RACF staff, participate in Advance Care Planning and treatment decisions.
The ‘person responsible’ can consent to treatment but cannot refuse treatment or consent to the withdrawal of treatment on behalf of the patient.
Step 4: Support discussion and Advance Care Plan
To assist the patient’s agent and/or next-of-kin in making choices regarding future medical treatments the patient can also complete an Advance Care Plan. This is designed to inform the agent, medical practitioners and facility/service staff of the patient’s choices. It holds evidentiary weight under Common Law and is not as legally binding as a Refusal of Treatment Certificate (RTC).
If the patient did not wish to provide any written instructions, the agent makes decisions based on the patient’s prior oral instructions or what the agent considers to be in the patient’s best interest.
For a patient who does not have legal capacity
If the patient does not have legal capacity, the agent or the patient’s relatives may choose to complete an Advance Care Plan –for a person who does not have legal capacity to make medical decisions form on behalf of a patient who can no longer express his or her wishes. Discussions can still occur including the patient to their full potential and with the patient’s family or loved ones. This should be done in the same way as with an adult with capacity, reflecting on the individual’s values, beliefs and goals. The Advance Care Plan can be completed by the patient’s family or loved ones in collaboration with the patient’s GP and staff caring for the individual. It is preferable to commence this process when the patient is well and in a non-crisis situation. This could be done using case conferences.
Discussion of patient’s wishes
An essential step in Advance Care Planning is for the patient to discuss and communicate their beliefs, values and goals for treatment. This discussion helps to direct decisions about specific treatments and provides a framework for the patient, the agent and the doctor to make treatment decisions in the future.
Patients need to understand their options for life-sustaining treatment and the value to them of this treatment. The discussion with their GP could encompass:
Current health status, Personal goals and goals of treatment, Benefits and burdens of relevant medical care, eg investigations, hospital transfer, antibiotics, fluids, tube feeding, surgery, resuscitation, and Whether or not the benefits and burdens of treatment are compatible with the individual’s goals, eg how active should treatment be, are there any limitations.
A patient’s preferences and goals may change as an illness progresses. Certain goals may assume higher priorities over time or short-term goals may be balanced against long-term goals. At times, individuals may have the goal of deferring as much decision-making as possible to others, eg the GP, palliative care team or family.
In considering an analysis of benefits and burdens, life-sustaining treatments may be viewed as beneficial if they:
Are effective in prolonging life, restoring function and relieving suffering. Promote a person’s goals and values. Are consistent with religious or cultural beliefs.
Life-sustaining treatments may be viewed as burdensome if they
Result in more or intolerable pain or suffering. Are damaging to body image or functioning, psychologically harmful, physically or emotionally restrictive. Do not promote a person’s goals and values. Are not consistent with religious or cultural beliefs.
See examples of discussion questions in the Reference Card: Advance Care Planning Discussion Guide.
Step 5: Complete a Refusal of Treatment Certificate (RTC)
If a patient is refusing a treatment that relates to a current illness, they or their agent/guardian may complete a Refusal of Treatment Certificate (RTC), according to the Medical Treatment Act (Vic) 1988.
See the Refusal of Treatment Certificate – Competent Person from the Office of the Public Advocate. A medical practitioner and one other person must witness the Refusal of Treatment Certificate. They must be satisfied that the patient is:
Over 18 years of age and has legal capacity, Clearly refusing general medical treatment or specific medical treatment for a current medical condition, Voluntarily making the decision to sign the RTC without coercion, Given reasonable and sufficient information about their condition, and Appears to understand the information.
See the Refusal of Treatment Certificate – Agent or Guardian of Incompetent Person from the Office of the Public Advocate. A medical practitioner and one other person must witness the Refusal of Treatment Certificate. An agent or guardian can refuse treatment for the patient they represent if they:
Have been given sufficient information about the patient’s condition, Understand this information, and Believe that the medical treatment would cause unreasonable distress to the patient or there are reasonable grounds for believing the patient would have considered the treatment unnecessary.
Palliative care
Under the Medical Treatment Act (Vic) 1988, a RTC does not allow the patient or the patient’s agent to refuse palliative care (e.g. reasonable pain relief, reasonable provision of food and water). Under common law, however, a patient with capacity has the right to refuse any treatment.
Medical trespass
While the Medical Treatment Act protects medical practitioners who, in accordance with a RTC, do not perform or continue to perform medical treatment, the Act also creates the offence of medical trespass. This occurs when a registered medical practitioner is aware that a RTC applies to a particular individual, and nevertheless undertakes or continues to undertake the medical treatment refused in the RTC. A doctor who provides treatment contrary to the express wishes of the patient who has executed a valid RTC could be putting him/herself at risk of legal action.
Step 6. Review the Advance Care Plan
Wishes expressed in the Advance Care Plan should be reviewed following a major change in the patient’s condition or after each hospital admission. In residential aged care facilities the Advance Care Plan should also be reviewed at the patient’s regular review meetings or case conferences.
There are a number of reasons why a patient might want to change or revoke a MEPOA, Advance Care Plan, or RTC. For instance, the relationship with the agent may change, or the person appointed may no longer be appropriate for the role, or the patient’s medical and other circumstances or wishes may change.
Advance care plan documents can be changed verbally or in writing. The patient may destroy the documents or request that they be destroyed. Completing a new document (eg, appointing a new agent or recording new choices) can also revoke documents as the most recent dated document overrides the older document. To revoke the Refusal of Treatment Certificate, it is advisable that the patient completes the cancellation section of the existing certificate. It is also important to inform the agent(s) and family members of the changes and provide them with copies of new ones.
Using an Advance Care Plan
The Advance Care Plan only comes into use when the person is no longer able to communicate his/her wishes.
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Using an Advance Care Plan
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Step 1. Document and communicate Advance Care Plan.
Step 2. Incorporate Advance Care Plan into medical care plans eg NFR document.
Step 3. Consult Advance Care Plan and patient/agent/person responsible when major clinical decisions need to be made.
Step 4. Review plan after a significant change in patient’s condition.
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Step 1: Document and communicate Advance Care Plan
The Advance Care Plan is designed to communicate patient treatment choices to family, RACF staff, after hours service providers, and on transfer to staff of hospital or other facility.
After the Advance Care Plan has been completed, the original remains with the patient and copies are provided for:
The agent and, if applicable, the alternate agent, Resident record at the RACF, Patient medical record at the GP clinic, Other hospitals/clinics the patient normally attends (with a covering explanatory letter), and Extra copies to share with others (eg. next of kin, minister or solicitor).
We recommend placing the patient’s Advance Care Plan prominently in a coloured plastic sleeve at the front of the resident’s record along with the Patient Summary and Care Plan. This ensures the plan will be consulted and have maximal impact on end of life care when needed, particularly after hours, or on transfer to hospital.
When the patient is transferred to hospital or another facility, a copy of the Advance Care Plan is sent with them.
If the plan is changed, the old plan should be destroyed and the new plan placed in the records.
Step 2: Incorporate Advance Care Plan into medical care plans
The Residential Aged Care Patient Summary and Care Plan and other treatment plans should reflect the patient’s wishes expressed on the Advance Care Plan or through the Advance Care Planning process.
The Advance Care Plan is considered a patient initiated document. Some facilities may require a medically initiated document such as a Not For Resuscitation form. This should be completed according to the facility protocol and reflect the patient’s choices. Medically initiated Not For Resuscitation forms will be filed according to the protocol of the facility/service.
A copy of the Not For Resuscitation form should be kept with the Advance Care Plan documents.
Step 3: Consult Advance Care Plan when major clinical decisions need to be made
The GP and RACF staff involved in medical care should know where the Advance Care Plan is, when to use it and the implications it may have for future medical treatment and end of life care.
In the event of deterioration in the health status of the patient, then the RACF staff, GP, visiting locum doctor and/or ambulance officer should consult the patient and Advance Care Plan. Also the agent, person responsible or next of kin should be notified as specified in the plan. Medical decisions can then take into consideration the resident’s health status and documented wishes.
Providing patient advocacy
In accordance with the Privacy Act, if a patient has not restricted their medical information, the Advance Care Plan or results of Advance Care Planning discussions can be shared with all health care professionals providing care to the individual. The GP should also advocate for the patient if a situation arises where another health service seeks to override the patient’s choices.
Step 4. Review plan after a significant change in patient’s condition
If there is a major change in the patient’s condition or the patient has returned from a hospital admission, the Advance Care Plan should be reviewed with the patient, along with other treatment plans. The patient may or may not wish to change some of their treatment and other Advance Care Plan choices.
Sources of Information
Where to go for more information
Office of the Public Advocate, Victoria
Address:5th Floor, 436 Lonsdale Street Melbourne Victoria 3000
Phone: Tel (03) 9603 9500, 24 hoursor Toll Free 1800 136 829
Fax: (03) 9603 9501
Email:publicadvocate@justice.vic.gov.au
Website:www.publicadvocate.vic.gov.au
Publications available from the website include:
DIY kit (9th Ed 2006) Take Control, a guide to powers of attorney and guardianship Fact Sheet – Medical enduring power of attorney Fact Sheet - The ‘Person Responsible’ Fact Sheet - Refusal of Medical Treatment Fact Sheet - Multilingual publications.
Victorian Legislation
To access the Medical Treatment Act 1988 go to www.dms.dpc.vic.gov.au
From Home Page of "Victorian Legislation and Parliamentary Documents" click on "Victorian Law Today" > Click "Acts" then alphabetical search "M" > click on Medical Treatment Act 1988 (option of Adobe or Word versions).
Victorian Association of Health and Extended Care (VAHEC)
VAHEC, Russell Kennedy Solicitors and Palliative Care Victoria have produced A Guide to Decision-Making in Health Care for people in the residential care, health and aged care sectors. A copy has been distributed to all RACFs in Victoria. For further information contact VAHEC on (03) 9820 0888 or email info@vahec.com.au
Respecting Patient Choices Program
For further information contact Ms Liz Stickland at Austin Health on (03) 9496 5660.
References
Larson DG, Tobin DR. EOL conversations: evolving practice and theory. JAMA 2000;284(12):1573-8. Austin Health. Respecting Patient Choices Project. Final Report to the National Institute for Clinical Studies. Sept 2003. Hammes BJ, Rooney BL. Death and End-of-Life Planning in One Midwestern Community. Arch Intern Med. 1998; 158:383-90. Health Issues Centre. Respecting Patient Choices. Evaluation Report of Consumer and Staff Involvement in Pilot Phase. June 2003. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
The guideline has been developed using the process outlined in the GP and Residential Aged Care Kit.
The information provided in this clinical information sheet is based primarily on Level 111 evidence from program evaluations done by Hammes and Rooney (3) and Austin Health (2). The level of evidence of references used to compile this clinical information sheet is provided in the table below.
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Reference |
Year |
Level of Evidence* |
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1. |
Larson DG, Tobin DR. EOL conversations: evolving practice and theory. JAMA 2000;284(12):1573-8. |
2000 |
Level IV evidence |
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2. |
Austin Health. Respecting Patient Choices Project. Final Report to the National Institute for Clinical Studies. Sept 2003. |
2003 |
Level 111 evidence |
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3. |
Hammes BJ, Rooney BL. Death and End-of-Life Planning in One Midwestern Community. Arch Intern Med. 1998;158:383-90. |
1998 |
Level 111 evidence |
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4. |
Health Issues Centre. Respecting Patient Choices. Evaluation Report of Consumer and Staff Involvement in Pilot Phase. June 2003. |
2003 |
Level IV evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [5] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Advance Care Planning to Improve End of Life Care
The following reference cards are designed to be used in conjunction with the Advance Care Planning to Improve End of Life Care Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
GP steps to advance care planning
Assessing a patient’s legal capacity
Advance care planning discussion guide
Resident information and documentation for advance care planning
Resident information and documentation for advance care planning - for a resident who cannot consent
Fact Sheets:
Enduring Power of Attorney (Medical Treatment)
The ‘Person Responsible’
Refusal of Medical Treatment
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