Guidelines for a Palliative Approach in Residential Aged Care

CHAPTER 4
ADVANCE CARE PLANNING
Care of any type involves decisions about how to actively pursue treatments, which treatments
to accept, and which treatments to refuse. These decisions take on greater complexity in
RACFs, where some residents may feel uncertain about discussing treatment options. An
advance care plan is an interactive process of communication between a competent resident
and the aged care team. The purpose of the advance care plan is to elicit the resident’s wishes
regarding treatment decisions, which will often include decisions related to their impending
death; to extend their autonomy, and to guide decision-making when the resident may be
rendered incompetent of doing so [68] (Level II). Advance care planning does not have to be a
legalised formal process. It should revolve around ongoing communication with the resident
and/or family, as communication is the fundamental principle of advance care planning.
The Code of Ethics and Guide to Ethical Conduct for Residential Aged Care (2001) [69] states
that providers should “…act in the best interests of residents in determining, particularly
before admission, whether or not the organization has the capability of providing them with
care appropriate to their needs” (p.9). The Code also emphasises the right of residents to make
choices about their care, including the right to refuse or agree to treatments offered. This code
is beneficial in providing the aged care team with direction regarding how to care for residents,
their families and carers. Another beneficial guide has been developed by the New South Wales
Department of Health, which is entitled Guidelines for Decision Making at the End of Life.
(Please note; these two documents are not research-based but reflect expert opinion).
4.1 IMPLEMENTING ADVANCE CARE PLANNING
Advance care planning empowers the individual to state their wishes in writing, in accordance
with how they define quality of life [14] (Level QE). By doing so, the burden of responsibility
is removed from the surrogate and control is maintained by the resident. When residents
are unable to express their own views regarding treatment, it is important for families to be
involved in all decisions about ongoing care, including the acceptance or refusal of certain
treatments. If these discussions do not occur, treatment decisions may be made by ‘default’,
resulting in unnecessary transfers to acute care settings or other interventions that may not be
in accordance with the goals of the aged care team and/or the family.
As with preparation of a will, these discussions can never occur too early, and having a
discussion about advance care planning before admission to an RACF is an excellent first step.
If this preliminary discussion has not occurred, a discussion will need to be initiated at the time
of admission. At this time, there may be special considerations if the resident is no longer able
to make their wishes known (see Chapter 5, ‘Advanced dementia’). Ongoing discussion and
updating of perceptions and wishes relating to advance care planning are also essential, as they
help ensure that communication on these matters remains current.
Guidelines for a Palliative Approach in Residential Aged Care 55