Advance Care Planning – good for patient care
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Advance Care Planning – good for
patient care and better use of health dollars?
Dr Ben
Gray
Advance Care Planning (or ACP) is the process of
thinking about, talking about and planning for future health
care and end of life care. In its delivery, this seems a
very clinically focussed, individual health care process, so
what relevance has it got for Public Health?
Actually a lot. We know that we spend around seven times more in the last year of life than the average spent in all other years of a patient’s life (2). This problem will be exacerbated as the baby boomers die.
Expenditure on dying people is
going to rise. However Advanced Care Planning can
potentially minimise this rise in health expenditure, saving
health dollars for use elsewhere in the system as well as
improving patient quality of life.
Advance Care Planning
has been introduced because it has been recognised that
collectively the health system is not good at doing
“informed consent” around the end of life. There are two
important reasons for this. The first is well illustrated by
my patient Joan (fictitious name).
“From 30,000
deaths in 2012, it is highly likely that deaths will exceed
40,000 in 2036. It is highly likely deaths will exceed
50,000 after 2051” (3)
Joan lived alone in a small
council apartment. She suffered from emphysema and had been
unable to stop smoking. Her world slowly shrunk as she got
more breathless. First she had to give up gardening. Slowly
she had more difficulty getting around her apartment. She
would have exacerbations requiring antibiotics but we
managed to keep her away from hospital. Eventually despite
24 hour oxygen she decided she could not manage at home
anymore and was admitted to a rest home. I remember visiting
her there and her telling me that she really did not want to
be there and that there was not much for her to live for.
Two weeks later she became unwell over the weekend and was
admitted to hospital with a chest infection. I visited her
on Monday afternoon. I saw her in her 4 bedded cubicle and
she said in a loud but very breathless voice “I don’t
want to live anymore.” I asked the staff what treatment
she was on and found that they were giving her antibiotics
for the chest infection. When I asked her if she wanted that
she said no. The antibiotics were stopped and she died a day
later. No one at the hospital had been able to have the
conversation with her about whether she wanted treatment or
not.
Source of picture
http://www.advancecareplanning.org.nz/personal/
The
second reason we need to improve end of life care is to do
with the fact that if you have a hammer then “everything
looks like a nail”. If you visit a surgeon or oncologist
with a cancer they will offer treatment. Sometimes they
offer treatment as a last chance without even giving any
idea of how big that chance might be. It even turns out that
some people live longer if given palliative care than if
offered interventional care (4). If a patient had thought of
and discussed their wishes in the last phase of life they
would be in a better position to question their clinicians
to find out why they were proposing treatment and what the
benefit of treatment would be. As long as a clinician’s
presumptions that extending life at any cost is worth it
goes unchallenged, ineffective intervention is more likely
to continue. This issue of “futile care” is well
summarised by Botha et al (1).
The health sector is
continually under financial pressure with endless calls for
more expenditure. In the last few weeks there have been
proposals for a bowel cancer screening programme, for more
funding for low cost primary care clinics and for better
wages for rest home workers – all potentially
cost-effective or the right thing to do, but what gives?
Prioritisation decisions are always hard. How would we weigh
the relative merits of those three proposals, and what would
we remove funding from in order to fund these?
Advance
Care Planning has a great potential to save health sector
dollars at the same time as improving patient care. If all
the patients like Joan could have their wishes for less
health sector resources provided, and we only offered
treatment to patients that we knew would be likely to
benefit, a lot of resource could be saved, making it easier
to fund other deserving options like the ones above.
Last month the result of a national cooperative process was launched in the form of a website and a large amount of supporting material. There is an e-learning platform for clinicians, and information for patients and their families on how to go about having a conversation about how they want to live until they die. Personnel are being trained as trainers in Advance Care Planning. This is an important initiative. The ground work has been done well and it is now up to all of us, planners, clinicians and the public as a whole to embrace the idea and give it a good run (with future evaluations being of course critical). Whoever thought that something as simple as a conversation had the potential to make such a difference?
References:
1.
Botha, J., Tiruvoipati, R., & Goldberg, D. (2013). Futility
of medical treatment in current medical practice. New
Zealand Medical Journal, 126(1383).
2. Chan, W. C.,
Jackson, G., Winnard, D., & Anderson, P. (2011). Healthcare
services funded by Counties Manukau District Health Board
for people in the last year of life. Journal of the New
Zealand Medical Association, 124(1335).
3. Statistics
New Zealand. (2011). National Population Projections.
4.
Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E.
R., Admane, S., Jackson, V. A., …Lynch, T. J. (2010).
Early Palliative Care for Patients with Metastatic
Non–Small-Cell Lung Cancer. New England Journal of
Medicine, 363(8), 733-742. doi:
doi:10.1056/NEJMoa1000678
ends