End-of-life planning framework calls for fewer checklists

A national framework for advance care planning would see Canada’s “tick-box” approach to preparing for the worst incorporated into a more formal process of ongoing communication and reflection between patients, their families and health care providers.

The framework, now in development by the Canadian Hospice Palliative Care Association (CHPCA), aims to shift the focus of advance care planning from patients making lists of the medical interventions they’d like to receive or refuse to a more flexible conversation about their values and the goals of care.

“Two years ago, people thought simply filling out a form was adequate advance care planning. Get the patient’s wishes down on paper and you’re good to go,” says Louise Hanvey, project leader of the team developing the framework.

It’s never been easier for Canadians to give instructions about the kind of care they’d want to receive but the extent to which those are followed, or are even useful, is limited, Hanvey says, largely because of a lack of awareness, training and infrastructure to support the communication required for effective advance care planning.

“We developed the forms to create these documents and the provinces got the legal supports in place to recognize them, but we didn’t develop the public education, professional engagement or system supports to use them effectively,” Hanvey explains.

According to a draft of the framework, effective advance care planning requires a number of conversations over time so that patients can articulate and clarify their wishes. Those should occur in a nonstressful environment and patients should craft written directions in consultation with their health care team and legal advisors. By these standards, most advance care planning in Canada is poorly executed, says Hanvey. End-of-life care typically isn’t broached until too late and many directives are not adequately prepared, communicated or utilized (www.chpca.net/projects/advance_care_planning/acp_environmental_scan_sept_9_09.pdf).

End-of-life care often isn’t broached until too late, when a crisis occurs or life-sustaining treatments have already been instituted despite a poor prognosis.

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The draft framework highlights the role that family doctors can play in encouraging advance care planning conversations before the diagnosis of a chronic or terminal illness. But Hanvey says health care professionals often lack the training to actively initiate those conversations.

The draft framework also recommends integrating advance care planning core competencies into undergraduate and graduate education; training frontline staff to routinely check if patients have plans or directives; and developing online continuing education programs for health care providers. It also calls on the provincial–territorial ministries of health to provide resources to compensate physicians for time spent on advance care planning.

The draft framework notes that effective advance care planning has been linked to increased patient and family satisfaction with care, fewer hospitalizations and less resource use in nursing homes, fewer life-sustaining procedures, lower rates of intensive care unit admissions and, for advanced cancer patients, substantially lower health care costs in the final week of life. The final version of the framework will be released “in the near future.”