Health System Factors

What is known

The important issue of when to start advance care planning conversations has been studied.  It is suggested that management of any 'serious illness' should include attention to advance care planning. [1]

A systematic review has identified a number of 'sentinel events' as important triggers for advance care planning for patients with cancer. [2] These include: new diagnosis with advanced cancer, admission to hospital or intensive care unit of a patient with cancer, new diagnosis of cerebral metastases, change in chemotherapy regimen, or when a cancer patient is identified as possibly having a need for haemodialysis, a pacemaker, an implantable cardioverter-defibrillator, major surgery, or a gastric tube.

A systematic review has identified a number of measures to assess the quality of advance care planning processes, however these need further development before being implemented as tools for quality improvement. [3]

An evidence based review of advance care planning in Australia recommends the development of uniform national policies, legislation and guidelines to support advance care planning, and also that financial incentives for health services should be introduced to support these policies. [4]

What it means in practice

  • Palliative care patients, by definition, meet the criteria of 'serious illness' and benefit from a systematic approach to advance care planning. This should include providing information about prognosis and the different options for treatment, how to know when things are changing, how the person can be supported and cared for if and when they choose a predominantly palliative approach, and prompting them to identify a surrogate decision-maker and to document their wishes as appropriate.
  • Doctors and other health care providers have a responsibility to help palliative care patients plan ahead by identifying likely transitions in their future care and ensuring that information about the patient’s wishes for treatment are available in those circumstances. This might include when travelling away from home, during any transfer by ambulance, if seen at an emergency department, or if requiring admission to hospital or residential aged care facility.
  • Starting or leaving any program of health care should trigger a review of advance care plans.
  • It has been recommended that staff be trained to actively seek and check advance care planning documentation, especially emergency staff. It is also suggested that as part of their care, nursing staff should monitor the congruence between patients’ stated wishes and their actual care. [4]
  • The Respecting Patient Choices program provides a process for promoting and supporting advance care planning, and maintaining the documentation of advance care planning conversations. It has been shown to have improved outcomes for patients and to generate systemic changes in health care services where it has been implemented.
  1. Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15;148(2):141-6.
  2. Walling A, Lorenz KA, Dy SM, Naeim A, Sanati H, Asch SM, et al. Evidence-based recommendations for information and care planning in cancer care. J Clin Oncol. 2008 Aug 10;26(23):3896-902. 
  3. Lorenz KA, Lynn J, Dy S, Wilkinson A, Mularski RA, Shugarman LR, et al. Quality measures for symptoms and advance care planning in cancer: a systematic review. J Clin Oncol. 2006 Oct 20;24(30):4933-8. 
  4. Street A, Ottmann G. State of the science review of advance care planning models. (291kb pdf) Bundoora, VIC: La Trobe University; 2006. 

Guidelines

Overview articles (free full text)

Last updated 17 January 2017