Quality is doing things with standards and palliative care means improving the care of patients who are dying. So overall, Quality palliative care to me is to take care of patients in their preference with standards and to ensure they have a comfortable stay. I chose advance care planning as my topic to research further about it. The main reason I chose this topic was to find out what is advance care planning all about, the importance of planning ahead and how does it benefit us in the future. It is not only taking care of patients, but it includes involvement of their family and friends which interest me to find out their roles
. Furthermore, when we hear the word palliative, we immediately think of elderly patients only, however, we do have young children in palliative care as well. This was another topic that made me want to find out more advance care planning. We will be discussing about what is advance care planning, the purpose of it, how can we make the public aware of advance care planning and the importance of it. After this discussion, you should be able to explain what advance care planning contains.
Advance care planning is early planning for death and how family can provide care. This can be provided for anyone who is expected to be terminally ill or have signs and symptoms of illness. It is better to prepare for advanced care planning earlier when patient is alert and able to communicate well. Advance care planning can be first done by thinking about the things needed for the patient to live meaningfully and what is important to them at their end of life.
If they have any health condition, it is important that they know their own prognosis and the available treatment options. The next step will be to discuss it with their loved ones about their goal and wishes. This should be shared with their loved ones who can be trusted and help them understand patient’s decision. It is also key to choose one or two people as their voice to make best decisions for them. After deciding, it is important to record patient’s wishes and share it with their loved ones. Once created, it can always be reviewed and edited according to patient’s wish.
Advance care planning is very important as it allows patients to decide in advance what care they want to receive if they become unable to speak for themselves. Rather than leaving their treatment options up to others, they can leave instructions that take their values and preferences into account and eliminate the uncertainty for his/her doctors and family members. We never know what can happen to their health. By deciding early, the patient’s voice is being heard and honours individual’s wishes.
There are 4 positive impacts of advance care planning in relation to quality palliative care outcome as evidenced by an article where a research was done in Australia and they realised after the education programmed that it is needed to start advance care planning. With advance care planning, it allows patient’s trusted family member to make decisions for them which fulfil the patient’s wish.
An example will be, if a patient had stroke, he/she might not be able to speak properly and because of this, the treatment or procedure done to patient might not be something he preferred. By having the family member there, it allows healthcare workers to be able to provide treatment and care as preferred by patient.
Another impact will be to improve outcome for patients as shown by evidence that planning for end of life care reduces stress, depression, anxiety in surviving relatives. As patient is aware of what are the possible procedures and medication will be given, patient will have less anxiety and knows that whatever mentioned by patient during advance care planning will be followed in the intervention.
Third impact will be patient’s satisfaction, patients or their family members gave positive feedback to questionnaire given upon discharge as satisfied to all the questions. It can be evidenced by the following, 272 (88%) questionnaires were completed by patients or family members whereby 133 were intervention and 139 were control. This shows that with advance care planning, it improves the quality of care and that is why patient and family members give feedback as satisfied for all the questions.
Fourth impact will be allowing future nurses or doctors to be aware of the patient’s wants. It might be too early for the patient to decide but at least if anything happen to patient unexpectedly, everyone will be aware on what the patient prefers. As death is not something that can be predicted, it is useful if advance care planning has already been done. Even though patient family might not have been ready, as nurses and doctors, we will know the report as advance care plan would have been already documented down, just as how and what the patient prefers at different situation.
An example will be, a sixteen-year-old girl, Nina Adriana took part in advanced care planning and she suffered from advanced chronic lung disease. As she took part in advance care planning, the nurses and doctors managed to provide care and treatment as she wished which is not to be under endotracheal intubation and ventilation for longer than five days. She did not want to have external cardiac compressions and advance life support measures.
In Singapore, we have advanced care planning in most of the hospitals such as Khoo Teck Phuat Hospital (KTPH) and Tan Tock Seng Hospital (TTSH). They have a team of doctors and nurses just for advance care planning who will be facilitating. There have been an increasing number of facilitators who are well trained to be facilitators. Minister of Health has also announced changes to palliative care sector by training staffs at 14 nursing homes in advance care planning, geriatric care and end of life. The inpatient capacity also upgrades by increasing the number of beds from 147 to 360 by 2020.
Facilitators will be discussing preferences with the patient such as cardiopulmonary resuscitation during a cardiac arrest, place where patient prefer to be receiving medical treatment if patient condition deteriorates. Not only an increase in facilitators but there have also an advance care planning clinic in the geriatric clinic started in Khoo Teck Phuat in 2013 which helps patient decide on end of life care.
In overseas, advance care planning are also practised. They felt that the discussion about advance care planning would have been overly medicalised, therefore the introduced a ‘Transactional Model’ which discuss about different aspects of care rather than all the medical jargon. In this model, we look at the patent’s perspective rather than biomedical perspective. It provides a personal view.
They also have this filling up of documentation such as Health Care Power of Attorney (HCPOA) and Practitioner Orders for Life Sustaining Treatment (POLST). These form shows the decision made by patient and the decisions and preferences made by the family member for the patient.
To promote quality advance care planning, we can have advance care planning as a mandatory form for all patients above 21 to decide. Like how in overseas, they have a form to document the decision made by patient and their family members, it can also be implemented in Singapore to provide such forms during admissions and explain to patient about the purpose of it. We can also promote advance care planning by putting up posters around hospitals, bus stops and advertisement in television and YouTube videos for everyone to be aware of it.
As plans are made, there are also challenges while trying to implement these ideas. The first challenge will be to bring forth the idea of having forms during admission about advance care planning. Patient or family members might immediately think that nurses and doctors are trying to say that their family member is going to pass away. Due to this mentality, it will be difficult to explain the purpose and benefits of advance care planning to them. Even before it is being explained by nurses or facilitators, patient or family members shut them off.
Another challenge will be to discuss advance care planning with patients with dementia. As Singapore is increasing elderly with dementia, it might also be difficult to discuss with them as they might not remember the decision they made and might ask to change many times during treatment and procedure. This might interfere with treatment and therefore, that is why it is important to start early to prevent miscommunication and confusion.
The third challenge will be protecting patient autonomy and avoiding harm for patient. As some patient, they might prefer passing away rather than to suffer and hold on to the pain whereas for other patients they might prefer to find ways to treat them. As advance care planning provides patient with what they have decided, it will slightly difficult to make decision as nurses and doctors. An example will be, use of euthanasia. In Singapore, it is legal to use euthanasia but there are different opinions about it. However, the point here will be, some patients might have decided that they want to die slowly with the help of euthanasia, but patient family members might not prefer that way. It brings a conflict here whereby as mentioned in advance care planning, we should respect and fulfil patient’s wish but on the other side, family members might not be in favour of that.
Lastly, more trained staffs will be needed to explain to patient about the pros and cons of advance care planning. Not all nurses or doctors will be able to approach patient and explain to them. Therefore, it is also necessary for nurses to be open minded and allow themselves to learn about advance care planning in palliative care.
The possible cause of these challenges will be due to lack of awareness about palliative care and advance care planning. If everyone is aware of the benefits of such services, I am sure they will be understanding and willing to accept to give the best care for their loved ones as well. Another cause can also be due to lack of time, as not many people prepare themselves for the worst which is death. By preparing ahead, we can voice out our wish and have people to fulfil them for us if anything happens. So, the earlier planning is done, more prepared we will be to face anything.
There are also tools to help with the quality bereavement support. There are questionnaires, go wish game, decision making fact sheet, consumer tool kit and five wishes for advance care planning. These tools can be used to provide support. An example will be the use of five wishes. This is an easy to use legal document whereby medical, personal, emotional and spiritual needs can be written down. It is also available online so anyone of any age can access to this. Such tools cane used during palliative care whereas to see if the method has worked, we can use questionnaire to evaluate the effectiveness of patient care. This will allow patient or family members to say their experience.
In conclusion, advance care planning is important and necessary for everyone ranging from different ages. Singapore government has been trying to raise awareness about advance care planning and provided training for staffs in hospitals. There is also advance care planning in other countries which involves questions to be completed to document patient’s wishes. As mentioned earlier, there are also many challenges regarding advance care planning as some patient might not be willing to do, because they feel that advance care planning is all about passing away. Lastly, we discussed about how to solve the problem in Singapore, by raising more awareness to the public and displaying advertisements and posters around.