Advance Care Planning: A chance to be proactive not reactive

Rebecca A Brooks, Internal Medical Trainee, Cambridge University Hospitals NHS Foundation Trust
Other Contributors:
Helen Hayhoe
Alistair J Mackett

June 14, 2020

Whilst the benefits of advance care planning are being increasingly recognised [1], the current Covid-19 pandemic has emphasised the continued importance of a proactive rather than reactive approach to end-of-life care.

In light of end-of-life care discussions around Covid-19, we reflected on our previous evaluation of the end-of-life care provided to patients with Parkinson’s Disease (PD) at Cambridge University Hospitals Trust. Notes of 61 patients who died between 2018 and 2019 were reviewed. We were encouraged to see evidence of good practice including open discussions around preferred place of care and prognosis. Sadly, this good practice only routinely occurred in hospital during their last illness. When we reviewed whether a proactive approach had been taken, only a minority of the patients had ever previously discussed prognosis (13%) and a smaller number still (3%) had an advanced decision to refuse treatment (ADRT) despite the vast majority of patients evaluated being in the palliative phase of PD. 15% did have Lasting power of Attorney in place.

Although Covid-19 is a novel disease the principles of advance care planning remain the same. We have arguably swung from one extreme to another. Our evaluation from 2019 demonstrated a trend for advance care planning to be carried out in the acute inpatient setting, which perhaps should be more accurately described as ‘last minute care planning’. Whereas in the early stages of the Covid-19 outbreak we saw evidence of a more de-personalised approach, such as a recent example of this occurring when a GP practice advised patients by with co-morbidities by standard letter to consider “Do not attempt cardiopulmonary resuscitation” forms to be filled in. [2].

Whether we consider patients at high risk of dying from Covid-19 or patients with chronic, life limiting illness, we should adopt an approach which is individualised and sensitive to patient need and expectations. The first step surely has to be to promote national discussion on death and dying thereby breaking down some of the barriers to timely, person-centred advance care planning.

  1. Rietjens J, Korfage I, Taubert M, Advance care planning: the future. BMJ Supportive & Palliative Care Published Online First: 15 May 2020. doi: 10.1136/bmjspcare-2020-002304 https://spcare.bmj.com/content/early/2020/05/15/bmjspcare-2020-002304
  2. Iacobucci Gareth. Covid-19: Don’t apply advance care plans to groups of people, doctors’ leaders warn BMJ 2020; 369 :m1419

Conflict of Interest
None declared

 

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