Why Advanced Care Planning Needs Urgent Attention 

InFocus Issue 21, January 2021

A rapidly aging population and a range of options for home and aged care in Australia pushed by the federal government have combined to result in an urgent need for aging patients, their families / carers, and GPs to discuss advanced care planning.

Geriatrician Dr David Shum recently held an advanced care planning webinar for GPs to explain how it can be discussed and managed with patient; the parameters regarding topics such as decision making capacity, comprehension, resuscitation and end of life care; and to reduce the confusion, discomfort and stigma around having these discussions with patients and if needed, their families.

Dr Shum said patients who have completed advanced care plans feel empowered and in control by having autonomy in their overall care. He said preserving patient dignity and supporting them to continue their life at a high quality was essential to their health.

Joining Brisbane Private Hospital in September this year, Dr Shum is a locally trained consultant physician who attained his fellowship with the Royal College of Physicians as a Geriatrician in 2015 and held a staff specialist position at QEII and Princess Alexandra Hospitals. He is also a visiting medical officer at Greenslopes Private Hospital and Sunnybank Private Hospital and regularly consults with patients in residential aged care via telehealth throughout Brisbane and regional Queensland, including in Sarina and Theodore and Roma.

“As a Geriatrician I take care of older adults, helping them with post-surgical care, reconditioning following major illnesses, general concerns related to aging such as memory, frailty, continence, and their ongoing independence. 

“I have special interests in dementia diagnosis, management, as well as in management of behavioural and psychological symptoms of dementia (BPSD). My inpatient interests include rehabilitation post joint replacement surgery, reconditioning following medical illness, and contribution towards complex discharge planning.  

“My role is to try to allow patients to age well and to keep them as independent as possible into their 80s and perhaps 90s, over the next couple of decades. With an aging population in Australia, if we don’t change our models of care and understand what our older generations need, the government will struggle to provide what is needed, so the general public needs to know why advanced care planning is so important.”

Resuscitation and End of Life
Dr Shum said the primary purpose of advanced care planning was to make sure that older Australians were well looked after and that they were receiving good medical care.  They need to be educated on the possibility of and not provided with unnecessary or inappropriate care, including some life-prolonging care which may be available thanks to medical advances, but not appropriate for quality of life.

He said that discussions and directions regarding resuscitation, for example, were very important because the actions that can be provided under hospital care are not what they look like in film or on television movies or on tv.  

“This type of care can often be very traumatic. I have had patients say that they want everything done to be kept alive, however they may think otherwise if they are aware of the trauma that CPR, artificial breathing and artificial feeding can cause. Most importantly, this rarely offers improvement in quality of life, even if it prolongs it. Often quality of life can suffer as a result because people may not fully recover, so patients really need to understand and be aware of what being given everything to stay alive means.  

“Advanced care planning includes discussions around actions where quality of life can be preserved, but not guaranteed, as well as a range of other topics, so we need to have education about what capabilities exist for patients, and at what cost.”

Dr Shum said as health practitioners, doctors don’t want to provide care that is inappropriate or harmful as it can be traumatic for patients, their families, and staff.

He said resuscitation and end of life decision making were areas that many patient groups, GPs and specialists felt uncomfortable discussing, sometimes for cultural reasons, so increasing the awareness of advanced care planning to help patients and families/carers discuss it with their GPs was vital.  

Capacity and Comprehension
“A significant proportion of the community doesn’t know that advanced care planning is available. I get many referrals from GPs asking questions regarding guidelines around decision making capacity, for example, with patients wanting to change their wills or appoint people to assist in their care.

“From an ethical position, capacity is deemed to be present until proven otherwise, so education around this is important because having patients need to prove their capacity takes away their autonomy. Concerns may be raised when they have obvious cognitive impairments. A simple score on an MMSE score alone is not an appropriate determination of capacity. 

“The health care provider also needs to explore a patient’s understanding of the question and comprehension. If a patient with a low MMSE score is still able to describe what they want and don’t want with their care, they may still be able to undertake advanced care planning.”

Steps for GPs
Dr Shum said for GPs, finding the opportunity to talk to or approach patients was the biggest barrier to discussing advanced care planning, so he suggested raising the topic during these areas of discussion:

1. When a family member asks about future treatment options for a patient;
2. When an age-related health care assessment is necessary;
3. During a visit for annual flu vaccine;
4. In the case of diagnosis of a malignancy, regardless of its severity;
5. If a patient is diagnosed with early cognitive impairment, as in the early stages they may still have the capacity to undertake planning;
6. When a change in care arrangements arises, such as a patient moving into aged care or with family. 

He also suggested that patients, family members/carers and GPs can visit the advanced care planning website to see what can be included in a plan to ensure all areas were considered at advancecareplanning.org.au.

“I have had the opportunity to explore what other countries are doing with their advanced care planning and Australia is very far ahead of others. However, we can do much better in improving our understanding of what our aging members of the community need and getting them to engage with family/carers and GPs to ensure a clear and smooth process for their advanced care, whilst maintaining their dignity and autonomy.”