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Advanced Care Planning is heavily promoted as a means to engage patients in meaningful dialogue about their end of life wishes (e.g. SpeakUp, ACPdecisions.org) However, the legal meaning and relevance of ACPs, advanced directives, and living wills is poorly understood.
Advance care plans, advanced directives, and living wills have no legal meaning. Instead, the Health Care Consent Act refers to “Treatments”, “Treatment Plans”, and “Prior Expressed Wishes”.
From SpeakUp, “Advance care planning is a process of reflection and communication, a time for you to reflect on your values and wishes, and to let others know your future health and personal care preferences in the event that you become incapable of consenting to or refusing treatment or other care.” Advanced directives and living wills are just other ways of saying the same thing – that a patient may, in advance, articulate their preferences for treatment in a hypothetical scenario. This can be very useful in terms of providing “prior expressed wishes”, but consent requires much more than this in order to proceed with a given treatment.
A common confusion is that advanced care planning will determine what treatment is ultimately provided to a patient. Treatments, and Plans of Treatment are only proposed by physicians, when they are relevant and indicated. Further, plans of treatment may deal with health problems that a patient “is likely to have in the future given their current health” [HCCA, 1996]. The implication is that just because a patient wishes something, does not require a physician to offer or provide it in the future.
For example, a patient may express in an advanced directive, or through an advanced care planning exercise that should they require it, they would wish to receive renal replacement therapy. Fast forward 6 months, and the patient is now in the ICU with MOF. If nephrology deems it inappropriate to offer dialysis at that time, it is irrelevant that the patient had expressed a wish to receive it. Of course, if dialysis is appropriate to offer, then it can be very important if we understand that the patient did not want it. So its not to say that advanced care planning isn’t important – we just need to be careful not to misrepresent it.
Advanced Care Planning does indeed have an important role in the care of our patients. However, we propose that this is ideally done in the context of discussions with a family physician when the preferences described are not likely to become a reality for a long time. Further, these conversations should be revisited regularly as patient attitudes and perspectives will evolve as their level of health changes or they experience different events (e.g. visiting a loved one in hospital).
When a patient is in hospital and their health trajectory is somewhat foreseeable, we propose that what is required is a plan of treatment that addresses health issues they are likely to have in the future, and that this is a matter of consent.