Advance care planning in an ageing population

Tim Robertson

6/05/2022 6:03:18 PM

People think their doctors should play more of a role in advance care planning, new research suggests.

GP discussing advance care planning with a patient
Most GPs believe patients should start advance care planning in their late 50s.

A paper exploring the cognitive and behavioural bias in advance care planning (ACP), published in Palliative Care and Social Practice, found that only 14% of the Australian population currently has an advance health directive in place.
And for Dr Stephen Whyte, a behavioural economist at Queensland University of Technology and co-author of the paper, the issue will become increasingly important considering the Federal Government reports the number of Australians aged 65 and over jumped from 8.3% of the total population in 1970 to 16% in 2020, with the figure expected to grow to between 21–23% by 2066.
‘The benefits are clear. For the individual involved, it can improve the quality of their end-of-life experience and assure their wishes are explicitly met, as well as alleviate stress and anxiety for loved ones,’ he said.
‘It can also dramatically reduce the psychological, emotional, administrative, and economic burden on healthcare professionals and systems.’
The research found that one of the main reasons the uptake of ACP is so low is a lack of patient knowledge.
Associate Professor Joel Rhee, Chair of RACGP Specific Interests Cancer and Palliative Care, agrees that ACP is not widely and well understood. He believes GPs have an important role to play in introducing the concept to their patients.
‘GPs can help answer many of the questions people might have,’ Associate Professor Rhee told newsGP.
‘Some of the issues people commonly think about when they’re doing advance care planning include what happens when they become really unwell, what’s the meaning of CPR [cardiopulmonary resuscitation] and lifesaving treatment. These are core health aspects [of ACP].
‘GPs can provide advice about the process and legal side of things, as well.
‘For example, explaining what an advanced care directive is and how it’s different to advance care planning and explaining what an enduring guardian or person responsible is.’
The researchers collected data from 1253 members of the Australian public aged 18–80, along with 117 nurses and GPs.
‘Previous research in this area has primarily focussed on sample populations of the seriously ill, and/or the elderly, and did not explore the role of bias in decision making,’ Dr Whyte said.
‘Our study provides new and novel empirical findings from both frontline healthcare professionals and potential future patients relating to ACP communication and preference.
‘Triggers for embarking on an ACP discussion are usually related to a significant new or ongoing health issue.
‘Interestingly, our study shows most people and GPs consider it apt to start such a discussion in their late 50s. Nurses, on the other hand, consider it a priority from a person’s early 40s, probably because they are the ones most involved in the day-to-day provision of end of life care.’
Associate Professor Rhee agrees that, in an ideal world, more patients would begin thinking about ACP earlier, but he concedes that there are resourcing constraints that mean this is not feasible.
‘If there were plenty of GPs who were able to give advice to everyone out there, including people who are 25 years old and completely healthy, then I think advance care planning and advance care directives should be recommended to everybody,’ he said.
‘But it’s one of those resourcing situations, so it makes sense for us GPs to think about facilitation with those who might benefit the most.’
There is no one-size-fits-all approach when it comes to ACP; however, GPs should think about initiating discussions about ACP with some patients more than others, Associate Professor Rhee explains.
‘Care really needs to be personalised and tailormade, and GPs are in a really good position to be able to do that because they know their patients really well,’ he said. 
‘You might have a patient who has some health challenges, a chronic disease or an advanced illness; in that situation, the possibility of them becoming very unwell in the future is increased and it makes sense for that person to think about these issues earlier.’
Associate Professor Rhee also points out patients may have very strong or specific views regarding end of life care.
‘For example, a person of Jehovah’s Witness faith … might decline treatment involving blood transfusion,’ he said.
‘Obviously, we can’t assume the patient will have those views, but it’s important to check with the patient and, because that’s such an uncommon view, it’s worth having that person think about their views and preferences and consider documenting them.
‘And advancing age is, of course, another factor.’
Associate Professor Rhee emphasises the importance of open and frank discussion between GPs and their patients and, if they choose to include them, their family and loved ones.
‘These discussions often strengthen the existing relationship, which is why the discussions are often more important than the outcomes, which might be the directive or the documentation,’ he said.
‘Having these discussions helps build trust, improves understanding and enhances relationships.’ 
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Dr Simon Mark Holliday   7/05/2022 1:34:15 PM

Its not that hard to systematise education on Advance Directives or Enduring Guardianships into nurse-assisted GP workflows.
We evaluated 42 consecutive home health assessments where the subject was raised by the nurse with a 2-page handout provided. It was followed up by the doctor when the HHA was reviewed. On average it took 5½ minutes of nursing time and 4 minutes of GP time. For over a decade, our practice has also routinely raised this area during care plans.