Where do advance care plans fall during a pandemic?

For residential aged care facilities (RACFs), where the majority of Australia’s COVID-related deaths have occurred, cracks have been exposed in the management of preventing spread of the virus.
 
There has been ambiguity regarding infection prevention and control standards and hospital transfer procedures, with reports suggesting many people of RACFs are not being transferred to the hospital after testing positive to COVID-19.
 
But for those residents who do get transferred to hospital, some GPs are expressing frustration about not being involved and, in some cases, being unable to fulfill their patients’ advance care plans, particularly if they die in hospital.
 
Associate Professor Joel Rhee, Chair of the RACGP Cancer and Palliative Care Specific Interests network, is concerned about hospitalisation and COVID-19, especially the use of secondary triage models and if it goes against a patient’s wishes.
 
‘Emergency physicians [can] prevent patients from being transferred to hospital by assessing them over a telephone,’ he told newsGP.
 
‘What’s concerning is that emergency physicians are specialists in emergency department, possibly critical care and retrieval settings. They have no expertise in managing patients in nursing homes.
 
‘This might prevent the patient’s advance care plan from being fulfilled if they wanted to be treated at the hospital.’
 
Associate Professor Rhee said that for GPs who have advance care plans in place with their patients, it is no surprise that COVID-19 has presented challenges in seeing those through.
 
‘In terms of how GPs can help patients stick to advance care plans in this situation, I think it’s a challenge because a lot of decision-making is out of the hands of the patient, family, the GP, or the aged care home,’ he said.
 
‘Not everyone’s wishes are going to be met; the duty of the Government and health officials to protect the health of the community needs to be balanced against the respect for patient autonomy.’
 
Despite such barriers in ironing out procedures, GPs can continue to be strong advocates for their patients by communicating their preferences to the people who are making the decision to transfer the patient to the hospital.
 
‘To be an effective advocate, GPs would need to understand the patient’s preferences, so it would be important for them to engage in advance care planning discussions with residents before their health deteriorated.
 
‘After the decision is made, then the GP could try to help the patient and the family understand the decision-making, especially if the decision is contrary to what they were expecting.’
 
Advance Care Planning Australia provides conversation starters for healthcare providers when talking with patients during COVID-19.
 
So what are the implications if a patient’s plans are not fulfilled – they die in hospital when they wanted to stay at the RACF, or vice versa?
 
According to Associate Professor Rhee, the GP’s liability and responsibility in this scenario would depend on many factors.
 
‘For instance, how clearly were the patient’s wishes expressed and communicated – were they clearly documented in an advance care plan? Is there any reason to suspect that the patient may have changed their wishes? How applicable is the [plan] to the situation at hand?’ he said.
 
‘It also depends on whether the patient was given treatment against their wishes, or was it the reverse? For example, they wanted certain treatments but they were not offered by the treating doctors.
 
‘The former would be highly concerning unless there were really good reasons for it, such as the patient had to be hospitalised against their wishes in the interest of public safety or health.
 
‘In the latter case, doctors are not obliged to offer treatments that are considered futile. Still, it would be good practice to try to work with the patient or the person responsible to come to a consensus about these decisions rather than unilaterally deciding without the patient’s or the responsible person’s input.’
 
Associate Professor Rhee also acknowledged that the decision might be out of the GP’s hands, especially if the patient tested positive for COVID-19.
 
‘If the authorities insist on transferring the patient to the hospital, or vice versa, for public health reasons, then there’s not much the GP or anyone else can do,’ he said.
 
‘This shows the importance of GPs getting involved in advance care planning.
 
‘Having discussions about the patient’s wishes early, and ensuring that the patient is fully informed about the decisions that they are making would help reduce the likelihood of future problems.’
 
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