Cross-Cultural Considerations in Promoting Advance Care Planning ...

Background
Advanced Care Planning in Canada
BACKGROUND
In Canada during the past decade, there have been national, provincial, and association reports identifying the
need for palliative care to include ACP as a tool to alleviate prolonged patient pain and suffering at the EOL (Canadian
Hospice Palliative Care Association, 2005; Ferris et al., 2002; Lomas, Culyer, McCutcheon, McAuley, & Law, 2005;
Quality End-of –life Care Coalition & Kort Consulting Services, 2004). The five committees established by Health
Canada working from 2002 through to March 2007 identified areas of interest that required further examination. On
their behalf, Health Canada commissioned several reports that speak specifically to Canadian issues regarding EOL care
and ACP.
The company, Barry Ashpole and Associates, Inc. was asked in the spring of 2005 by the PIAWG to complete
an environmental scan to assess the current activity in ACP in Canada, Australia, and the United States. The report
concluded that there was little reliable evidence in Canada that the implementation of ACP ensured that individual’s
preferences, whether indicated in a conversation, or documented were heeded. A review of provincial and territorial
legislation and regulation demonstrated inconsistency in terminology and a lack of clarity in understanding the
meaning of various terms and legalities for both health professionals and the general public. While a number of
ACP or Advance Directive initiatives were undertaken in several provinces, the integration of this type of tool was
fragmented and in the very early stages of any kind of evaluation (Barry Ashpole and Associates, Inc., 2005).
Donna Wilson in her 2003 synthesis of Canadian EOL programs and policies indicates “there is a great deal of
disparity in end-of-life care available across Canada” (Wilson et al, 2003b, p.10). She identifies that differing levels of
program development exist across regions, provinces, and the country; that mature programs are a result of visionary
pioneers and individuals who have lobbied health systems for support; there is need for more supportive action on the
part of governments at all levels; that palliative care services are not readily available for non-cancer patients; and that
there are too few educated health professionals in the palliative and EOL care field (Wilson et al., 2003b).
In 2006-2007, Health Canada provided funding to the Educating Future Physicians in Palliative and End-of-Life
Care (EFPPEC) Project Team for development of an interprofessional education program about ACP. The project
created educational competencies in ACP, an ACP facilitator’s guide, and is currently completing the curriculum
content. Since there are differences in the laws, legislation and regulations across Canada it has been difficult to
complete a legal framework that satisfies everyone involved. However, it is hoped that the curriculum will be integrated
into the educational programs at several universities in 2008. Although the cultural considerations of ACP have not
yet been incorporated into the curriculum, the CIHR Cross-Cultural Palliative NET has submitted a grant that would
provide knowledge translation funding intended to facilitate integration of this material.
2.1. Culture Definition
Understanding diversity in the EOL is a challenge and one of the difficulties lies in semantics. Concepts such
as race, ethnicity and culture are referred to in research, but definitions of these concepts are vast, complex and
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