Advance Care Planning and End-of-Life Care

This assignment delves into the crucial topic of advance care planning and its influence on end-of-life care for elderly patients. It requires a critical analysis of research studies, exploring both the positive impact of advance care planning on decision-making and quality of care, as well as the challenges in implementing this process effectively. The focus is on understanding how advance care planning functions as a health behavior change strategy and its implications for various stakeholders, including healthcare professionals, patients, and families.

Running head: ADVANCE CARE PLANNING FOR PALLIATIVE CARE 1
Advance Care Planning for Palliative Care
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ADVANCE CARE PLANNING FOR PALLIATIVE CARE 2
This essay centers on the case study of Anthony Vella, aged 46. Six months ago, Anthony
diagnosed with stage four pancreatic cancer. Anthony has been going for a chemotherapy since
he was diagnosed with cancer, until two weeks ago, when his oncologist told him that
chemotherapy is no longer effective against his condition. A few days later, he experienced
severe abdominal and nausea, where he was admitted to the oncology ward. With the help of the
palliative team care, Anthony significantly improved and he decided to return home. A week
later, Anthony collapsed and was non-responsive. An ambulance took him to a major hospital,
where he was taken to the emergency department.
The remaining part of the essay explains advanced care plan (ACP) and how it could
have been of benefit in the case study of Anthony Vella. This paper is structured into six parts.
The first part is to define advance care planning and its possible benefits for Anthony. Explaining
the point at which ACP discussion should be initiated then follows. The section that follows
clarifies who should take part in the ACP discussion. The information that should be included in
the ACP is the next section. The advance care plan is that is inclined to changes over time.
Therefore, the part that follows is when the ACP can be reviewed. The last part of this essay
discusses when the ACP should be activated. As a final point, a summary of all the points
discussed is wrapped up in the conclusion part.
Definition and benefits of Advanced Care Planning
Advance care planning is a procedure that enables people to plan for their future medical
treatment and care when they can make a rational decision (Rizzalli, 2010). It is a platform that
allows individuals to express their wishes, objectives, beliefs, and values to their friends, family,
and caregiver before any health crisis occur. The purpose of ACP is to ensure that a patient's
wishes are known, understood and upheld as described by Holley (2005). ACP also helps by

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making things easier for family and caregivers as they will understand what the patient wants
when he or she is too ill or unable to speak. Advance care planning is typical in context of life-
limiting condition or a terminal illness.
There are numerous benefits attached to ACP that include less aggressive medical care,
taken care of as per according to the patient's wishes, reduced rate of hospital admission, mostly
in the care home residents and reduced hospital bills as explained by Heale & Noble (2017).
Research shows that 57% of patients who have completed ACP spent reduced time in the
hospital when nearing the end of death (Detering, Hancock, Reade, & Silvester, 2010).Advance
care planning is also crucial in enabling family and friends to prepare for the passing of a loved
one. It also helps in resolving family conflict and with bereavement as described by Curtis
(2008).
In the case of Anthony Vella, ACP could have assisted in knowing what his final wishes
were and how to address them. This was helpful especially when he became non-responsive and
could not speak. He could have undergone ACP two weeks ago when his doctor indicated that
chemotherapy is no longer effective. Since stage four pancreatic cancer is considered a terminal
disease with only 1% survival rate of five years (American Cancer Society, 2016), ACP could
have worked perfectly in the case of Anthony.
Advance care planning helps individuals decide on the future care which is taken into
consideration the moment the person loses capacity. It also increases the chances of the patient to
set up for other documents such as advance directives (AD), which explains the kinds of
intervention they would like to undergo (Spruit et al., 2013). Having both AD and ACP
documentation minimizes family conflict while increasing likelihood of respecting patient's will
as Detering, Hancock, Reade, & Silvester (2010) explains.

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Initiating advance care discussion
Different indicators can make a person go through ACP discussion. It can be due to a
life-changing event such as the death of a spouse, following diagnosis of life-limiting conditions,
a substantial shift in clinical focus, assessment of individual needs and multiple hospital
admissions, just to mention a few. ACP discussion should be an agreement among the patient,
caregivers, and families. The discussion should not be as a result of outside pressure, for instance
from family members.
Adams, Kabcenel, Little, & Sokol-Hessner, (2015) outlined a sequential step that
healthcare organization could take into consideration while preparing ACP discussions: engage,
steward, respect, exemplify and connect. The first step is to engage with both the patient and
family members to understand what matters to most of them. This is followed by stewardship
which entails documenting the healthcare delegation and what is relevant to the patient regarding
his health care (Adams, Kabcenel, Little, & Sokol-Hessner, 2015). The exemplify step involves
making the patient understand how ACP could be of benefit to them by showing examples of
healthcare staffs that have undergone through ACP discussions. The final step is to connect with
the patient in a respectful way both physically and culturally.
A patient should discuss ACP when he or she is physically and mentally well enough for
the patient to participate in the discussion fully and subsequently make a sound decision. The
discussion should focus on their goals, cultural and religious beliefs, and values instead of other
conditions such as dementia (Fried, Bullock, Iannone, & O'leary, 2009).
In the case of Anthony Vella, ACP discussions should have been initiated when the
oncologist told him that chemotherapy has stopped to be effective. This is the time when

ADVANCE CARE PLANNING FOR PALLIATIVE CARE 5
healthcare provider could have convinced him to undergo the ACP discussion when he was still
of sound mind (Fried, Bullock, Iannone, & O'leary, 2009). According to the case study, it can it
is to acknowledge that what matters to Anthony was spending time with his wife. However, there
were no records of the religious and cultural background of Anthony, neither was there any
medical care of his preferences to be applied once he became non-responsive.
The participants of Advance Plan Discussion
The ACP discussion involves some people, key among them are the healthcare providers,
the patient, and the family members. Concerning our case study of Mr. Anthony, the participants
should include his wife and his two children, professionals from his cancer team, preferably the
oncologist, among many other people (Bakitas et al., 2009).
If the patient has been accessed and found to be lacking the capacity to decide by
himself, a reliable individual can present the patient's best interest. For example, when the patient
is admitted to an emergency department, and is unconscious and requires immediate treatment. A
person who is acutely aware of the patient's wishes, preferences and values can step in to make
the decision needed (Bakitas et al., 2009).This is the case of Mr. Anthony since he was admitted
to the emergency department and did not have ACP at hand.
Information in Advanced Care Plan
Unlike Advance Decisions, Advance Statements and Powers of Attorney which a person
can make at any convenient time, Advance Care plan is made when a patient nears the end of
life. It mainly contains the patient's care and treatment wishes. These records are attached to the
medical notes where they can be of use in cases of emergency. If the patient has already made

ADVANCE CARE PLANNING FOR PALLIATIVE CARE 6
Advance Decision, Advance Statement or Powers of Attorney, the information should be part of
the Advanced Care Plan (Adams, Kabcenel, Little, & Sokol-Hessner, 2015).
Preferred Priorities for Care (PPC) document contains some questions that are used to prompt
the patient. The questions mainly revolve around "what matters to you?" (Adams, Kabcenel,
Little, & Sokol-Hessner, 2015). Doctors and other healthcare providers use this document when
deciding what is in the patient's best interest. PPC contain questions such as where you want to
receive care, where you want to be cared for when you are dying and where you prefer to die,
who you want to be next to you, values such as cultural and religious beliefs, and any dietary
requirements you will need (Fried et al., 2013). These questions help caregivers to understand
what is crucial to the patient and subsequently, their quality of life.
According to the research done by Sudore and Fried (2010) on what sort of information
should be included in the APC, recommended that AD forms, what matters to the patient and the
Powers of Attorney. The document should ensure that the proxy understands their role, taking
into account whether the surrogates should be given liberty or adhere strictly to the patient's
wishes. The Proxy is also responsible for informing friends and families of the wishes of the
patient (Heale & Noble, 2017).
For the patient to make ideal decisions or choices, they should consult with the healthcare
providers. The nurses are in a position to explain different types of treatment and options and
how the choices will affect the patient and whether the patient's decision is realistic or not.
ACP document should be written in a simple language that all parties involved can easily
understand it (Heale & Noble, 2017). This makes it much easier for those who are not much
conversant with legal terms and technicalities to comprehend the information contained therein

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to implement the wishes of the patient entirely. This also reduces the occurrence of
misunderstanding between proxy's decisions and wishes of the patient (Robinson et al., 2009).
Regarding the case of Mr. Anthony, his ACP information on who takes over the power of
making decisions when he was non-responsive. This could have been his wife or any other
unbiased individual. His wife should have stepped in and helped in making decisions that are of
the best interest of the patient. His wife or any other person taking the role of the proxy should
have been reasonably ascertainable, is aware of Mr. Anthony's past and present wishes, as well
as his feelings. Mr. Anthony should have appointed his health lasting power of attorney to take
charge when he is incapacitated (Robinson et al., 2009).
When to review Advanced Care Plan
Murray and McLoughlin (2012) explained that chronic illnesses could take place in any
of these three forms, acute illness signified by immense decline in physical health, for instance,
cancer, long-term sickness that a person becomes ill for long duration marked with periodic
occurrence of severe ill-health and a prolonged decline of physical health like in cases of
dementia or aging. Healthcare providers help in observing the patient for a given period and
subsequently categorize the patient into one of the three mentioned classes. This information is
important as it creates awareness to both the patient and family members. The information
gathered is used to come up with an ideal ACP and how to handle end of life issues Holley
(2005).
No specific recommendations or evidence point out to when to review ACP. Mostly, the
decision to consider the ACP is based on the patient's personal experiences. Some factors can
also lead to the review of ACP such as if the individual circumstances of the patient changes, for

ADVANCE CARE PLANNING FOR PALLIATIVE CARE 8
instance, place of residence or discernment of quality of life. Also, a new therapeutic approach
may become available, and therefore, the possibility of the patient recovering. As the condition
of the patient progresses, goals and values may change, which can affect the earlier decided on
the ACP Holley (2005).
Advance care planning should regularly be reviewed either to uphold or to amend
something while the patient is still in a capacity to do so. This ensures that the ACP is a
reflection of the patient's current wishes and also to increase its likelihood to be regarded as
relevant and up to date when the opportune time Michael et al. (2013).
Most cancer patients find ACP as a very dynamic document instead of a rigid one. As the
illness progresses, the person's views may change Michael et al. (2013). Mr. Anthony being in
stage four of pancreatic cancer might have felt the same. That is why he decided to spend the last
few days of his life with his family rather than in hospital. If he could have already had a standby
ACP, he could have changed his wishes. Mr. Anthony's ACP should have been addressed during
the early periods of his cancer treatment. This could have given him time to adjust his ACP at
different stages of the disease process. The ACP could have been reviewed the moment he was
informed that the chemotherapy is no longer effective.
Activating the advanced care plan
The decision of when to activate the ACP is based on the patient's condition. If the
formulation of ACP is per according Michael et al. (2013), then the activation of the document
can take place either immediately or over a given period. When the ACP is activated, the proxy
took over the role of a patient and now become in charge of the healthcare decision. Proxy only
makes a decision when the patient is incapacitated, and therefore, unable to make a sound

ADVANCE CARE PLANNING FOR PALLIATIVE CARE 9
decision. The proxy temporarily takes over the role of making a decision that is of best interest to
the patient until the patient regain knowledge, skills, abilities, and willingness to manage his or
her ACP (Adams, Kabcenel, Little, &Sokol-Hessner, 2015). The activation of the Advanced
Care plan can only move forward if all the stewards agree with the wishes of the patient. All the
parties should comply with the five conversation-ready principles Michael et al. (2013).
In the case of Mr. Anthony, if the ACP could have been ready, then it could have been
activated the time he collapsed in the marketplace and later become non-responsive. His proxy
would have made the decision regarding his healthcare based on his wishes on the ACP.
Conclusion
The essay addressed the matters regarding advance care planning with Mr. Anthony, a
cancer patient with stage four of pancreatic cancer being the reference point. Mr. Anthony
situation helps in understanding why it is important to prepare Advance Care Plan that can be
easily followed when a patient becomes incapacitated. ACP contains the patient's wishes
concerning the treatment and care, where to receive care, who they want to be with, their
preferred diet, where to receive care, among other things. AD, lasting healthcare power of
attorney and other relevant documents should be attached to the document should be attached to
the ACP. The reviewing of the ACP should be done from time to time to have an up to date
report. In cases where the patient cannot make sound decisions, activation of the ACP should be
contemplated.

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