Background
Advance care planning (ACP) is a means of extending the autonomy of people to stages in life where they lack capacity. [4,8,9] Loss of capacity may be temporary (e.g. severe acute illness, delirium), progressive (e.g. cognitive impairment or dementia) or permanent (e.g. stroke or advanced dementia). [6] Old age is associated with a high prevalence of chronic illness, comorbidity, frailty, cognitive impairment, and repeat hospitalisations [6-8,10,12,14,16] and 50-80% aged care residents have dementia. [6] The process of ACP is, therefore, particularly relevant for older people and aged care residents. [6-8,10,12,13]
In practice, discussions around end-of-life issues may often not take place or start too late. [13] Research shows that only 14% of the Australian population has an advance care directive (ACD). [17] Internationally, there is a low prevalence of advance care planning in residential aged care [7,8,12] despite a majority of residents welcoming the opportunity for such a discussion. [8]
Evidence Summary
ACP is intended to enable adults to make plans for their future care. The process encourages people to reflect on their values, preferences, beliefs, and to record how they want to be cared for at a time where they cannot communicate decisions about medical care for themselves. [1-9,11,12] ACP enables adults and their family to consider what care and treatments might or might not be acceptable. [1-5,8,11,12]
An Advance Care Directive (ACD) may result from ACP. An ACD is a document which provides a legal means for a competent adult to nominate and instruct one or more Substitute Decision-Maker(s) (SDM) and/or to record preferences for future health and personal care. [1,2,4,8-10] Forms of ACD include living will, advance directive (AD), advance health directive, advance personal plan, medical direction, do-not-resuscitate (DNR) order and do-not-hospitalise (DNH) or physician orders for life-sustaining treatments (POLST) and refusal of treatment certificate. [1-4,6,9,10,12]
ACP is most common in end-of-life care (the last 12 months) or terminal care (the last days to weeks of life). However, ACP is a beneficial process for all adults, especially those who are at risk of deterioration in health. [3,11,13] In case of loss of capacity, illness or injury, whether expected or not, ACP assists family, friends and health professionals to consider options and make decisions in line with a person’s wishes. [1-3,7-9,11-13]
In Australia, the state and territory government laws vary on ACP and ACDs. ACDs are legally binding documents in every state and territory. [2,3] Ideally, these documents should be completed with input from a treating doctor and a discussion of prognosis, possible complications and treatment options. [7-11,18]
ACP can improve end-of-life care in line with an older person’s wishes and satisfaction with care, [3,4,6,8,13] and it can reduce family stress, anxiety and depression. [4,5,13] ACP or ACD is associated with:
- decreased life-sustaining or burdensome treatment [4-6,10,13]
- earlier or increased use of hospice and palliative care [4-6,13,14]
- fewer hospital admissions, visits to ED, days in hospital and deaths in hospital. [4-6,10,13,14]
ACP programs seem to increase compliance with patients’ end-of-life wishes [4,5] and the chance of dying at home or in residential aged care. [6,10] People with dementia with an ACD in place are less likely to die in hospital or in ICU [11] or undergo burdensome interventions such as ED transfer and hospitalisation in the last 3 months of life. [10]
ACP appears to be associated with reduced healthcare costs for some people in some circumstances [5,6,13] such as people living with dementia in the community, people in residential aged care [6] or in areas with high end-of-life care spending. [5] There is no evidence that advance care planning increases healthcare costs. [5]
Quality statement
Overall, the quality of the reviews is good.
Page updated 22 October 2018