Read the full August eNews & President’s Message.
Advanced Care Planning – A Personal Perspective
Having an advanced care plan easily available to any health care professional—be it home care nurses, paramedics with EMS or nurses on an active care unit in hospital—is very useful. In our own clinic, we discuss a personal directive with every patient who has a review of their complex care plan. It would be good to include follow-up and incorporate a Green Sleeve to ensure completion of a personal directive. On reflection, why only during review of a complex care plan; why not incorporate this into an annual review with any patient?
I’ve recently had a very personal brush with legal documents such as Power of Attorney and Personal Directive. I was recognizing signs of illness in my own father and had embarked on obtaining these documents in a proactive manner. However, it may not have been truly proactive when one sees a family member deteriorating as proactive means doing this before something happens. My father then became seriously ill and was hospitalized quite suddenly before I had these documents ready. In the weeks following, I had to have documents transferred from my lawyer in Red Deer to a lawyer in Calgary, then have that lawyer meet with my father in hospital to get a Power of Attorney and Personal Directive in place. My father had the capacity to remain his own agent while this was being pursued, however, it could just as easily not have been the case. And, in all honesty, it was truly the Power of Attorney that was most important to my father. He was bedridden in hospital and could not look after his affairs (even though he knows the value of his bank accounts better than I know mine). Since having the Power of Attorney, I have looked after a tax installment, insurance payments and other bills, and my father is very relieved.
Is having the Green Sleeve on the refrigerator door the best place? I’m not sure. It needs be with the patient in question. I know of one case in which the family had done all the right things for a member of the family receiving palliative care. The Green Sleeve was on the door of the fridge, but this patient rapidly deteriorated, paramedics were called, but the Green Sleeve had disappeared (no one knows to where) and, as a result, there was no personal directive. A husband had to watch his terminally ill wife receive CPR when this was explicitly not her wish, yet there was nothing he could do.
The bottom line is to advocate with your patients to be proactive and explicit about advanced care planning and to have those plans readily available for when and where they are needed. It truly does provide a much higher quality of care for your patient.
Thanks for relaying your personal story and reflections, Fred. I hope your father is recovering.
I appreciate your suggestions about incorporating advance care planning discussions in visits with your patients. Some colleagues will rightly argue that they do not have time to do this with every patient. But there are particular patients in everyone’s practice who we can expect are most likely to encounter the health system, and who will undoubtedly benefit from having a PD, a Goals of Care Designation Order and most importantly, a conversation with their family members and health care providers. Many resources exist to assist with these conversations, including on our website – http://www.conversationsmatter.ca – and we encourage that these conversations ideally start in the family doctor’s office.
Regarding your query about the ideal location for the Greensleeve… The convention is the fridge or a drawer right next to it, and paramedics know to look for it there. But no location is a fail-safe one. The tragic story you recounted about the husband and wife speaks powerfully of the need to have PDs and Goals of Care Designations (which are medical orders) front and centre in any patient data stored in and accessible within a future provincial Clinical Information System. Ideally, they should be within Netcare as a key piece of clinical data about our patients, especially as they encounter sectors of the health system along with providers who are unfamiliar to them. Work to make that possible is slowly underway, but advocacy from community physicians and from patients is required to make it a priority.
Regards, Eric Wasylenko MD