Discussing advance care planning

As medical technology advances, many patients are living longer with diseases once considered deadly.
 
‘Things like cancer and HIV have become much more like chronic disease, with people often living with them rather than dying from them,’ Associate Professor Joel Rhee, Chair of the RACGP Cancer and Palliative Care Specific Interests network, told newsGP.
 
This situation provides a greater opportunity to talk with patients about advance care planning – a written record of a patient’s preferences for future care, in the event they may be unable to communicate these to their doctors and family.
 
Because of the long-term relationships they often have with patients, many believe GPs are well-placed to help people get started on this process.
 
However, patients and GPs can both experience a number of barriers to discussing advance care planning – including the simple difficulty of raising the issue in the first place.
 
‘It’s one of those things where the patients often expect the health professionals will raise it, while the doctors prefer the patients to raise it first,’ Associate Professor Rhee said.
 
‘I think another issue is because of the legality associated with advance care planning; if doctors are not completely sure or confident, it’s unlikely they’re going to raise the issue themselves.
 
‘Another thing is, sometimes [GPs] might feel if they start the discussion it’s going to take a long time and they don’t have time to talk about it for 15–20 minutes.’
 
Associate Professor Rhee and his research team conducted a study in which they investigated what kind of measures might help general practice teams overcome these barriers to facilitate conversations about advance care planning. They recruited four practices for the study, providing training and resources for GPs and practice nurses, whom the team considered to be key players in the process.
 
‘Initially, practice nurses’ main role was assisting the GP by helping out in procedures and following people up, that kind of thing,’ Associate Professor Rhee explained.
 
‘But gradually that role has been evolving so that they’re much more interested in getting involved in chronic disease management and having a bit more autonomy.’


Patients were encouraged to include their family in discussions about advance care planning. 

Each practice was encouraged to identify five patients with whom to discuss and deliver advance care planning, and set up an appointment between those patients and a practice nurse.
 
‘We encouraged the patients to bring their family members to these discussions, then have a robust and frank discussion with the nurse,’ Associate Professor Rhee said. ‘There was no limit to how many conversations could take place, so it was completely up to the patient and the nurse.
 
‘Each consultation took about 30 minutes or thereabouts, and at the end of it many of the patients ended up creating an advance care directive document. And the GP got involved in that, checking the patient’s wishes and helping in signing off those documents.’
 
The research team found that patients responded well to these appointments.
 
‘We weren’t 100% sure how the patients would react to having these conversations with the practice nurses, but they really found it useful and enjoyed talking with them,’ Associate Professor Rhee said.
 
‘The patients mostly weren’t concerned about whether [they spoke with] a doctor or a nurse – it’s more the relationship. They felt they could talk to the nurse and the nurse knew them well and could communicate well, and that was really important to the practice patients.’
 
However, the research was surprised when the study revealed a significant difference between general practice and palliative care when it comes to advance care planning discussions.
 
‘Although we’d designed for a conversation where the patient would bring in their significant other and their family members, that didn’t happen – and that was really interesting to us. We weren’t expecting that,’ Associate Professor Rhee said.
 
‘That’s quite different, I felt, compared to what palliative care would do, where a patient is unwell and the family would get together with the patient, and the whole team and sit down to have this in-depth conversation.
 
‘But in general practice what seems to happen is, a fairly well patient has the conversation with their nurse and GP and after everything’s finished they go back and have a secondary conversation with their family.
 
‘I think that’s really important to know, because what we need to now do is give support for these patients because some of them felt they weren’t necessarily ready to have this conversation with their family; we need to take this into account and maybe give some training or support for our patients to do that.’
 
The research results have recently been published in BMC Palliative Care. Associate Professor Rhee hopes there will be more to follow.
 
‘The next step would be to conduct a bigger study where you have a large number of patients and practices, and see whether this kind of thing can be replicated in a larger scale,’ Associate Professor Rhee said.
 
‘The other studies we’d also be interested in doing would be looking at how we actually help patients to have these conversations with their families.’
 
Associate Professor Rhee’s ultimate hope is that such conversations may one day become routine in general practice.
 
‘We hope that patients will feel comfortable and confident in being able to have this conversation with GPs and practice nurses; that we would all be able to give good advice to patients who are unsure or uncertain,’ he said. ‘That would be the goal.’

advance care planning general practice nurses palliative care