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Advance Care Planning (ACP)

Key Messages

  • Advance Care Planning (ACP) encourages adults to reflect on and discuss their values and preferences to plan for health or personal care at a time when they do not have the capacity to make or communicate decisions. [1-9]
  • ACP encourages a person to appoint a substitute decision-maker (SDM) and to document any specific wishes regarding their future care in an advance care directive (ACD). [1-3,8-11]
  • An ACD is a legal written advance care plan, completed and signed by a competent adult, which records his/her preferences for future care and appoints an SDM to make decisions about health and personal care. [1-3,9,10]
  • Although often about end-of-life care (the last 12 months) or terminal care (the last days to weeks of life), ACP is a beneficial process for all adults, particularly for older, frailer people and those with chronic or life-threatening illness whose health is likely to deteriorate. [3,6-8,10-13]
  • ACP can improve end-of-life care in line with a person’s wishes. [3-6,8,10,13,14] It can improve the chance of dying at home or in residential aged care [5,6,10] and reduce hospitalisation and burdensome treatment at end-of-life for older people. [4-6,10] This suggests the need for better awareness and education in ACP. [15]
  • In Australia, ACP and ACDs are governed by state and territory legislation. [2,3]

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 created 21 November 2017
 
  • References

  • About PubMed Search

  1. Queensland University of Technology (QUT). Advance Directives [Internet]. 2017 [cited 2017 Nov 21].
  2. Austin Health. Advance Care Planning Australia [Internet]. 2017 [cited 2017 Nov 21].
  3. The Royal Australian College of General Practitioners (RACGP). Advance Care Planning [Internet]. 2017 [cited 2017 Nov 21].
  4. Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med. 2014 Sep;28(8):1000-25. doi: 10.1177/0269216314526272. Epub 2014 Mar 20.
  5. Dixon J, Matosevic T, Knapp M. The economic evidence for advance care planning: Systematic review of evidence. Palliat Med. 2015 Dec;29(10):869-84. doi: 10.1177/0269216315586659. Epub 2015 Jun 9.
  6. Martin RS, Hayes B, Gregorevic K, Lim WK. The effects of advance care planning interventions on nursing home residents: A systematic review. J Am Med Dir Assoc. 2016;17(4):284-93. 2016 Apr 1;17(4):284-93. doi: 10.1016/j.jamda.2015.12.017. Epub 2016 Feb 6.
  7. Beck ER, McIlfatrick S, Hasson F, Leavey G. Health care professionals' perspectives of advance care planning for people with dementia living in long-term care settings: A narrative review of the literature. Dementia (London). 2017 May;16(4):486-512. doi: 10.1177/1471301215604997. Epub 2015 Sep 16.
  8. Gilissen J, Pivodic L, Smets T, Gastmans C, Vander Stichele R, Deliens L, et al. Preconditions for successful advance care planning in nursing homes: A systematic review. Int J Nurs Stud. 2017 Jan;66:47-59. doi: 10.1016/j.ijnurstu.2016.12.003. Epub 2016 Dec 8.
  9. Sechaud L, Goulet C, Morin D, Mazzocato C. Advance care planning for institutionalised older people: an integrative review of the literature. Int J Older People Nurs. 2014 Jun;9(2):159-68. doi: 10.1111/opn.12033. Epub 2013 Jun 20.
  10. Dwyer R, Stoelwinder J, Gabbe B, Lowthian J. Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: A review of patient and organizational factors. J Am Med Dir Assoc. 2015 Jul 1;16(7):551-62. doi: 10.1016/j.jamda.2015.03.007. Epub 2015 Apr 28.
  11. Dixon J, Karagiannidou M, Knapp M. The effectiveness of advance care planning in improving end of life outcomes for people with dementia and their carers: A systematic review and critical discussion. J Pain Symptom Manage. 2017 Aug 5. pii: S0885-3924(17)30333-0. doi: 10.1016/j.jpainsymman.2017.04.009. [Epub ahead of print]
  12. Dening KH, Jones L, Sampson EL. Advance care planning for people with dementia: a review. Int Psychogeriatr. 2011 Dec;23(10):1535-51. doi: 10.1017/S1041610211001608. Epub 2011 Aug 26.
  13. van der Steen JT, van Soest-Poortvliet MC, Hallie-Heierman M, Onwuteaka-Philipsen BD, Deliens L, de Boer ME, et al. Factors associated with initiation of advance care planning in dementia: a systematic review. J Alzheimers Dis. 2014;40(3):743-57. doi: 10.3233/JAD-131967.
  14. Hall S, Kolliakou A, Petkova H, Froggatt K, Higginson IJ. Interventions for improving palliative care for older people living in nursing care homes. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007132. doi: 10.1002/14651858.CD007132.pub2.
  15. Palliative Care Australia (PCA). Advance Care Planning - Position Statement (85kb pdf). Canberra: PCA; 2008.
  16. Cardona-Morrell M, Benfatti-Olivato G, Jansen J, Turner RM, Fajardo-Pulido D, Hillman K. A systematic review of effectiveness of decision aids to assist older patients at the end of life. Patient Educ Couns. 2017 Mar;100(3):425-435. doi: 10.1016/j.pec.2016.10.007. Epub 2016 Oct 11.
  17. White B, Tilse C, Wilson J, Rosenman L, Strub T, Feeney R, et al. Prevalence and predictors of advance directives in Australia. Intern Med J. 2014 Oct;44(10):975-80. doi: 10.1111/imj.12549.
  18. Robinson L, Dickinson C, Rousseau N, Beyer F, Clark A, Hughes J, et al. A systematic review of the effectiveness of advance care planning interventions for people with cognitive impairment and dementia. Age Ageing. 2012 Mar;41(2):263-9. doi: 10.1093/ageing/afr148. Epub 2011 Dec 8.

Definitions

Advance Care Planning

Discussions with patients and/or their representatives about the goals and desired direction of the patient's care, particularly end-of-life care, in the event that the patient is or becomes incompetent to make decisions (Source: MeSH Thesaurus)

Advance Directives

Declarations by patients, made in advance of a situation in which they may be incompetent to decide about their own care, stating their treatment preferences or authorizing a third party to make decisions for them (Source: Bioethics Thesaurus).

Search notes

Note: Searched only Aged plus RAC with topic and topic by itself

Advance Care Planning

((Advance care plan*[tw] NOT Medline[sb]) OR advance care planning[mh])

Advance Directives

advance directives[mh] OR ((advance directive*[tw] OR living will*[tw]) NOT medline[sb])