Advance Care Planning

Definition and Importance:

• document containing an individual’s values, beliefs, life goals and expressed wishes relating to healthcare, finances and lifestyle decisions, that will help guide future life decisions in the unfortunate future event that the individual loses capacity to make informed decisions
• Involves discussing values and healthcare preferences with family, friends, and healthcare team.
• Ideally results in a formal, written advance care directive.

Components:

• Advance Care Directive:
  • Addresses values and/or instructions.
  • Ensures preferences are respected.
  • Includes choice of a ‘medical decision maker’ for making decisions if the person is unable to communicate.

Benefits:

• Improves quality of end-of-life care and death experience.
• Ensures adherence to patients’ wishes.
• Enhances patient and family satisfaction with care.
• Initiates earlier provision of palliative care, potentially prolonging survival.
• Increases chances of dying in the preferred place (e.g., RACF with palliative care).
• Reduces hospital length of stay for elderly patients admitted from RACFs.
• Promotes communication, reduces distrust and conflict between family, friends, and healthcare practitioners.

When to Initiate:

• GPs, with longstanding trusted relationships, are well-positioned to initiate advance care planning.
• Fits well with discussions on healthcare options, diagnosis, and prognosis.
• Important for patients who may lose the capacity to communicate their preferences during their illness trajectory (e.g., cancer treatment, acute life-threatening illness, early dementia).

Ideal Timing:

• Early initiation, when patients are well and able to discuss and plan.
• Recommended during 75+ health assessments, chronic disease management, early dementia or frailty stages, or at RACF entry.

State and Territory Variations:

• Forms and requirements vary.
• Resources available for competent adults and those lacking decision-making capacity.
• Information and forms can be found at Advance Care Planning Australia.

Assessment of Decision-Making Capacity:

• Assumed unless evidence suggests otherwise.
• Capacity can fluctuate and is specific to the decision at hand.
• People should be involved in decisions to the maximum extent possible.
• Capacity assessment should be timely and consider the decision, options, outcomes, and rationale.

Decision-Making for Incapacitated Individuals:

1. Advance Care Directive: Made before losing capacity, providing treatment directions.
2. Substitute Decision Maker: Makes decisions based on the person’s presumed wishes and best interests.
3. Tribunal or Courts: Can provide consent or make treatment decisions.

In Queensland, the hierarchy for substitute decision makers, as defined by the Powers of Attorney Act 1998 (Qld), is as follows:

1. Guardian Appointed by the Queensland Civil and Administrative Tribunal (QCAT):
   • If a guardian has been appointed by QCAT specifically for health matters, they take precedence.
2. Enduring Power of Attorney (EPOA):
   • If the person has appointed an attorney under an enduring power of attorney for health matters, this attorney acts as the substitute decision maker.
3. Statutory Health Attorney:
   • If no guardian or enduring power of attorney is appointed, the statutory health attorney can make decisions. The hierarchy is:
     • Spouse: The person’s spouse (including de facto) if the relationship is close and continuing.
     • Primary Carer: An individual who is not a paid carer but has the primary responsibility for providing domestic services and support to the person.
     • Close Friend or Relative: Someone who has a close personal relationship with the person through frequent personal contact and interest in their welfare.
4. Public Guardian:
   • If no one else is available or appropriate, the Public Guardian can act as the substitute decision maker.

Hierarchy Summary

1. Guardian appointed by QCAT
2. Enduring Power of Attorney (EPOA)
3. Statutory Health Attorney:
   • Spouse
   • Primary Carer
   • Close Friend or Relative
4. Public Guardian

Responsibilities and Considerations

• Best Interests: Substitute decision makers must act in the best interests of the person, considering their known wishes and values.
• Decision Scope: They can make decisions about medical treatment, including consent to or refusal of treatment, based on what the person would have wanted.
• Consultation: They should consult with healthcare providers and other relevant individuals to make informed decisions.