The Definition of Advance Care Planning


The Definition of Advance Care Planning

Advance care planning (ACP) is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. This process can be facilitated by a specially trained health professional or can occur as part of routine care with the person’s usual health professionals.

The ACP process ideally results in the designation of a health care proxy, and in the creation of a written plan, commonly referred to as an advance directive, which accurately reflects the individual’s goals, values, and wishes about future healthcare. Since goals and medical treatment decisions may change over time, especially if overall health or if a person’s situation changes, planning needs to be reviewed. The types of planning may vary depending on whether the person is healthy, has mild to moderate chronic illness or is likely to die in next 12 months. ACP is therefore ongoing, and is subject to continual re-evaluation and possible updating, triggered by key health or life experiences.

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Advance Care Planning Programs

The concept of ACP programs arises from the understanding that it requires a systematic approach to implement and maintain ACP in a specific health care setting (facility, region, nation etc) so that patients’ wishes are known and can be followed. Essentially, ACP programs rest on two pillars:

a) On the individual level, providing a communication process as described above, facilitated by skilled non-physician and physician staff.

b) On the system level, ensuring there are processes for patients to be offered ACP, and to allow patients to record their wishes in a standardized way so they can be stored, retrieved as required and ultimately allow the person’s wishes to be known and respected. Thus health care services need to have appropriate policies and systems in place. Additional components of successful programs include staff education, defined roles and expectations of physicians, and adequate training for advance care planning facilitators, doctors and other members of the health care team. Successful ACP programs are usually proactive, appropriately timed, and integrated into usual care. Program evaluation and ongoing development and refinement of programs are also important. Finally advance care planning programs need to ensure that as patients move across health care settings, documentation of their wishes and goals of treatment travels with them.

Essential elements of advance care planning programs:

Modification to “Five Promises” (Respecting Patient Choices) as suggested by beizeiten begleiten (“Seven Elements”):

1. Initiate conversations about ACP with all adults who need to plan.
2. Skillfully facilitate planning with each individual
3. Provide professional written documentation
4. Make sure all plans are available when needed

5. Actively support continual actualisation of the plan and / or disease-specific planning in the trajectory
6. Follow plans in a thoughtful and respectful way
7. Install a process of continual quality assurance

The Goals of Advance Care Planning and Establishing an Evaluative Framework

Currently there are no accepted standards or evaluative framework for ACP; however, work in this area is evolving. In principal, there should be a common set of goals used to evaluate the effectiveness of any ACP program or system. These agreed upon goals will assist with consistent measurement across programs.

Common Goals of ACP

1. Enhance patient and family understanding of their illness including prognosis, the full range of treatment options, and the likely outcomes of these treatment options.
2. To create an effective care plan that includes
a. The selection of a well-prepared healthcare agent when possible
b. Specific instructions that reflect informed decisions geared to a person’s state of health or illness