Examining changes to advance care planning laws

Amanda Lyons

23/03/2018 2:04:05 PM

Associate Professor Joel Rhee talks to newsGP about recent changes to Victoria’s advance care planning laws, and how more financial support for GPs could help encourage greater uptake among patients.

Changes to Victoria’s advance care planning laws enable patients to make decisions in their directives that cannot be changed by families or medical professionals.
Changes to Victoria’s advance care planning laws enable patients to make decisions in their directives that cannot be changed by families or medical professionals.

Advance care directives were enshrined in law in Victoria earlier this month with the implementation of the Medical Treatment Planning and Decisions Act 2016. Associate Professor Joel Rhee, GP and Chair of the RACGP Cancer and Palliative Care Specific Interests network, believes the new legislation represents a positive change for patients and GPs.
‘It is now  easier, as a doctor, to discuss advance care planning with your patients, because you can actually point to an Act and the regulations around it, whereas before you had to talk about common law which is always less certain,’ he told newsGP. ‘So it’s a positive step.’
The Victorian changes addressed previous confusion and lack of clarity by defining the components of advance care directives in detail and setting them into legislation.
‘[The Act] describes advance care directives in three different components,’ Associate Professor Rhee said. ‘The first is the values directives, the second is instructional directives, and the final one is appointing a person to make decisions on your behalf, if you are unable to do so.
‘And it does it in a legislative way, which is quite different to some of the other states. For instance, New South Wales doesn’t really have a specific legislation relating to advance care planning or directives, so a lot of New South Wales is reliant on common law.’
These legislative changes significantly alter the way family and substitute decision-makers can make choices on behalf of the patient.
‘Before, when patient’s families and appointed decision-makers were making decisions, these were based on the best interests of the patient,’ Associate Professor Rhee explained. ‘So that takes into account what they think the patient’s wishes are, but it also goes beyond that into things like the wishes and values of the family members or the carers.
‘[Under the new legislation], it is very clear one is not deciding on the best interests of the patient; rather, it’s based on how the patient would have made the decision for themselves, which is a slightly different thing and very much about patient autonomy.’
These legal changes enable patients to make decisions ahead of time in their instructional directives that cannot be changed by families or medical professionals in the event that the patient can no longer speak for themselves; for example, that they do not want to be resuscitated. However, Associate Professor Rhee believes such instructional directives will not necessarily be very common.
‘I think a lot of patients might not choose that because it’s legally binding and ties your family’s and health professionals’ hands,’ he said. ‘There might be uncertainty around the prognosis and you’re not 100% sure you won’t want CPR under any circumstance.
‘So what you might want to do in that situation is appoint a person to make decisions on your behalf. Then you can give them guidance on how they’re going to make that decision by completing the values directive, and they would be bound to use that as the basis for their judgements.’
Associate Professor Rhee would like to see more advance care planning done in the community, and hopes the legislative changes in Victoria may encourage greater uptake. However, he believes there is one major barrier to realising this goal: funding.
‘There is no specific Medicare item number that GPs can use to discuss advance care planning,’ he said. ‘For us to make [advance care planning] available for everybody, GPs need to spend a lot of time with patients. But the existing Medicare system is acting as a barrier, and that is unfortunate.
‘I think the government has to encourage GPs to do it and if that means they’ve got to put in an extra item number, I think they should.’
GPs’ inability to fund the time needed to discuss advance care planning results in disadvantage for a particular cohort of patients.
‘There’s a whole group of people who may not be health literate or have very high educational backgrounds who would really benefit from [advance care planning], but because of the fairly complex nature of these documents and the process, they might not be able to easily understand and navigate the whole path,’ Associate Professor Rhee said.  
‘GPs really have an important role in bridging that gap and being able to advocate for those patients and explain the process to them.’
Associate Professor Rhee advocates for more funding because he would like all patients to be able to access the benefits that come from completing an advance care plan, which go beyond the plan itself.
‘One aspect of advance care planning is completing the documents, but another aspect is the discussion that comes around completing them,’ he said.
‘A lot of patients, when they have an advance care plan and have engaged in those conversations, feel a sense of having more understanding of their illness and of what kind of future they want for themselves, and I think that’s quite comforting for them.’

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