Case Study: Advance Care Planning and End-of-Life Decisions, NURS1137

This case study examines the case of Melissa, a 37-year-old woman with stage 4 bowel cancer, focusing on her advance care planning and right to determine the time and place of her death. The study explores the concept of advance care planning, the legal framework in Victoria, and the perspectives of patients in palliative care. It discusses the Voluntary Assisted Dying Act 2017, ethical dilemmas faced by healthcare professionals and family members, and their responsibilities in providing assistance. The assignment considers Melissa's specific circumstances, including her family situation and the challenges she faces in making end-of-life decisions. It also examines the eligibility criteria for voluntary assisted dying and the importance of effective communication in addressing ethical issues. The case study aims to provide a comprehensive analysis of advance care planning and its implications for patients like Melissa and the healthcare system.

Running Head: Assessment 3: Advance Care Planning
ASSESSMENT 3: ADVANCE CARE PLANNING
(THE RIGHT TO DETERMINE THE TIME AND PLACE TO
DIE)

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Assessment 3: Advance Care Planning
Table of Contents
Introduction................................................................................................................................3
The concept of advanced care planning.....................................................................................3
The right of a person to determine the place and time of death.................................................4
Discussion about ethical dilemma..............................................................................................6
Responsibility of healthcare professionals and family members in providing assistance for
determining time and place of death..........................................................................................7
Conclusion..................................................................................................................................8
Reference list..............................................................................................................................9

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Assessment 3: Advance Care Planning
Introduction
Advance care planning is a sensitive part of healthcare industry and legal boundaries
of this part differ in different places. This study is focusing on a case study of Melissa, who is
suffering from stage 4 of bowel cancer. She has experienced a lot of tragedies in her life and
this disease is forcing her to leave her parents and two children. Raising two children and
being separated from parents have made her a stronger personality. At present, she is
concerned about her medical condition and she has agreed to cooperate with the concerned
healthcare team in terms of her Advance care planning. Aim of this study is to evaluate her
right to determine the location and the time of her death. Current Victorian legislation for this
kind of cases is being discussed in this study.
The concept of advanced care planning
The process of advance care planning helps in promoting care that is consistent with
individual goals, beliefs, values and preferences. As stated by De Lima et al. (2017),
advanced care planning helps patients and their family members to plan for future health
decisions when the person may no longer be able to take own decisions. In this care process,
the person's values and current health conditions are discussed openly. This helps in making
decisions for future care. In this case, Melissa had frank conversations with her oncologists
several times. This has made her aware of the poor prognosis and she got the opportunity to
discuss future process of care. Australia's Victorian state government has developed a
different framework for providing end of life care. Main vision of this state government is to
provide optimal end of life care that can help to reduce pain and suffering of patients and
their families (Health.vic.gov.au, 2018). Advanced care planning is the central idea of
framework of Victoria's end of life care. This framework provides different resources and
tools that provide rights to people to talk about death. According to Victoria’s legislation, this

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Assessment 3: Advance Care Planning
framework is applicable to those patients who are likely to die within 12 months
(Health.vic.gov.au, 2018).
The right of a person to determine the place and time of death
Perspective of patients of palliative care unit regarding death
People, who are having end-of-life care, face mental distress at several times. As
mentioned by Hudson et al. (2015), patients with incurable disease first face the challenge of
accepting the fact that he or she must die in some days. It is challenging to accept this hard
truth and be prepared to leave closed ones. In the current case, Melissa is raising two children
single-handedly and her parents live far from her location. It is clear that her children need
her badly in their lives. However, her medical condition is not allowing her to stay with her
children for a long time. As per the case scenario, Melissa is a strong personality and she can
make decision of her death on her own. As opined by Townsend (2019), with the passage of
time, this kind of patients loses their mental stability in later stages of their life to make
appropriate decisions. Some of them consider one of their family members to make decisions
on their behalf. However, there are some patients like Melissa, who do not have a caring
family member to make decisions. Her children are not mature and her parents are not fit to
travel Victoria daily.
According to Duckett (2017), this kind of patients prefers to be a part of advance care
planning and wish to determine place and schedule for their death. For example, Melissa is
self-independent and strong enough to decide the schedule of her death. Victoria is the first
state that has successfully enacted the bill that permits patients like Melissa to decide about
their death. This kind of patient and their concerned healthcare providers must have
knowledge regarding existing laws that can support the patient in making decisions regarding
time and place of death. As stated by Yoong, Franco, William & Poon (2018), making this
kind of decision must be hard and challenging as family members and the patient go through

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Assessment 3: Advance Care Planning
an emotional face. However, the benefit of making this decision is to spend the last minutes
of life according to own wish. Patients like Melissa has the legal right to take part in Advance
care planning and decide the schedule of death. However, cooperation is required for all the
related person (Karapetis et al. 2018). For example, it can be said the mental support from
family members and caregivers make patient mentally strong while making decision about
their death.
Legal support to determine the place and time of death
Many cancer patients prefer to decide dying to get rid of the pain and suffering. A
voluntary assisted dying allows patients of end-of-life care units to decide the time and place
of their death. According to Beardsley, Brown & Sandroussi (2018), autonomy of the patient
must be given in all the cases. However, it must be considered that the patient is eligible to
make this crucial decision of life. Victoria is the first state of Australia that has to think about
the pain of people with cancer and other non-curable diseases (Sheahan, 2016). The Victorian
government has passed the Voluntary Assisted Dying Act 2017 (Victoria) to allow people
to decide the location and time of their death. In case of intolerable and non-curable
suffering, this Act allows the patient to apply for death (Legislation.vic.gov.au, 2019). This
act has been designed and recommended by the expert, Professor Brain Owler, the former
president of the Australian Medical Association in 2017. The Voluntary Assisted Dying Bill
2017 has been introduced in 29th November 2017. Aim of introducing this bill was to
enhance end-of-life care for Victorians.
This Act came into action on June 2019 and this Act can help Melissa to make
decision regarding the location and time of her death. Two primary practices have been set by
the Victorian regime regarding this fact. The practice of "Self-administration" allows patients
to administer a lethal substance prescribed by the doctor on their own (Legislation.vic.gov.au,
2019). This can be challenging for Melissa as it is difficult to kill self. As per the legal

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Assessment 3: Advance Care Planning
guidance, doctors are not legally bound to be present at the time of death on the
predetermined location. Additionally, as per this Victorian law, Melissa can request the
concerned healthcare team to be present at the time of her death (Health.vic.gov.au, 2018). It
will totally upon her whether she wants her family members to be present at the time or not.
However, no one is legally bound to attend this pathetic event. According to Yoong, Franco,
William & Poon (2018), sometimes patients in palliative care unit wish to die, but they are
not able to make it on their own. In those cases, the legal guidelines ask the concerned doctor
to perform the process. This practice is called "practitioner administration", where the legal
system provides the responsibility of administering a lethal substance to the concerned
medical practitioner (Theconversation.com, 2019). As stated by Kirby (2018), both of these
practices create an ethical dilemma in medical practitioners and the family members of the
patient. In case of Melissa, it is difficult to make her children understand these practices.
Melissa needs to discuss this matter with her beloved ones and they must understand the
situation of Melissa.
Eligibility criteria have been set to allow someone to access voluntary assisted dying. As
stated by Karapetis et al. (2018), a person must be aged above 18 and must be mature enough
to make such a big decision. It is important to be a citizen of Victoria, Australia, to apply for
voluntary assisted death (Legislation.vic.gov.au, 2019). The person must be able to
understand, retain and weigh all the guideline regarding the Voluntary assisted death. In this
case, Melissa is passing all of these criteria and she is able to communicate her decision
regarding the location and time of her death with all. Hence, she has the legal right to decide
the location and the time of her death.
Discussion about ethical dilemma
Legislative support like Victorian Assisted Dying Act 2017 can provide patients with
terminal diseases like cancer a dignity at the end of their lives. The government believes that

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Assessment 3: Advance Care Planning
each and every patient with terminal disease deserves right and dignity to end their lives
without suffering. However, Beardsley, Brown & Sandroussi (2018) stated that for
healthcare practitioners it is unethical to assist a patient to death. Duty and responsibility of
physicians and nurses are the main cause of ethical dilemma in this case. Principles, codes,
and ethics state that a healthcare practitioner must provide quality care that enhances positive
outcome of a patient. In this case, Melissa is suffering from a life-ending disease of cancer
and she has every right to determine the time of her death. In addition, she can even want to
receive advanced care at home or in any healthcare setting. As stated by Kirby (2018), the
virtue theory of ethics can be used to solve the dilemma regarding end of life care. This
theory states that different acts need to be performed for achieving a greater good. Hence,
family members and physicians need to provide value to the decision regarding time and
place of death of a patient with a terminal disease.
In addition, physicians can face an ethical dilemma regarding the treatment process of
the patient. They may get confused regarding continuing or ceasing the process of treatment
(White & Willmott, 2018). This problem can be solved through the process of advanced care
planning. Melissa can be provided with the right of choosing place and time of death.
According to her wish, future care planning can be done properly. ACP can help healthcare
professionals to discuss different needs of the patient and proper value to the wishes can be
given through it (White, Willmott & Close, 2019). Effective communication can help to
eliminate the ethical dilemmas and thus right of determining the place and time of death can
be provided.
Responsibility of healthcare professionals and family members in providing assistance
for determining time and place of death
It is the responsibility of the healthcare professional to let the patient make a request
first of assisted death by determining time and place of death. Role of doctor, in this case, is

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Assessment 3: Advance Care Planning
to coordinate with the patient that can help to provide required value to melissa. After the
request regarding time and place of death made by patient, doctors need to assess the
eligibility criteria (Pursuit.unimelb.edu.au, 2017). For example, measuring vital signs
regularly and conducting different lab tests to analyze the present condition of the patient.
After this process, the health practitioner such as an oncologist, in this case, can suggest the
available end of life care. For example, if Melissa chooses home as a place of death then the
oncologists and other care persons need to provide advice about related costs regarding the
process. In addition, in the voluntary assisted dying act 2017 (Vic), it is mentioned that
assisted dying can be done by the patients themselves or through medical practitioners.
Hence, the oncologists, in this case, must play their roles in assisted dying of Melissa that can
help to provide proper respect and value to this person.
Family members also need to play specific roles during provision of end of life care.
As stated by Street, Ottmann, Johnstone, Considine & Livingston (2015), mental strength
must be provided to the patient with terminal disease by the family members. Moreover, they
must support a person's choice of death. According to Victoria's legislation, a person who is
an Australian citizen and aged 18 years or above has every right to choose the time and place
of death (Pursuit.unimelb.edu.au, 2017). Hence, family members of Melissa like her father
and mother need to support the decision, which can help to provide proper value and respect.
Conclusion
From the above discussion, it can be concluded that end of life care is an essential part
of treatment that recognizes and respects patient’s wishes. Carers can better provide better
support to the patients by providing a choice regarding place of care. In victoria, there is
legislation regarding assisted death and end of life care. However, there are some ethical
dilemmas that can be mitigated by following the framework of advanced care planning
framework and legislations.

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Assessment 3: Advance Care Planning
Reference list
Beardsley, C., Brown, K., & Sandroussi, C. (2018). Euthanasia and surgeons: an overview of
the Victorian Voluntary Assisted Dying Act 2017 and its relevance to surgical
practice in Australia. ANZ journal of surgery, 88(10), 956-958. Retrieved from:
https://onlinelibrary.wiley.com/doi/pdf/10.1111/ans.14513
De Lima, L., Woodruff, R., Pettus, K., Downing, J., Buitrago, R., Munyoro, E., ... &
Radbruch, L. (2017). International association for hospice and palliative care position
statement: euthanasia and physician-assisted suicide. Journal of palliative
medicine, 20(1), 8-14. Retrieved from:
https://www.liebertpub.com/doi/pdfplus/10.1089/jpm.2016.0290
Duckett, S. (2017). Arguing in the Public Square: Christian Voices Against Assisted Dying in
Victoria. Journal for the Academic Study of Religion, 30(2). Retrieved from:
http://search.ebscohost.com/login.aspx?
direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=2047704X&AN=126
549176&h=gYdPWguDGNgYbDS3PqHn7PMO4lkOE2R8DPQsVUf%2BNrHnjG
%2F5K3XEzVG8k4Cm9Rldrw0ZtGecFaouIsN1KdJ44g%3D%3D&crl=c
Health.vic.gov.au (2018), Victoria’s end of life care and framework, retrieved from:
https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-
care/palliative-care/end-of-life-and-palliative-care-framework
Hudson, P., Trauer, T., Kelly, B., O'Connor, M., Thomas, K., Zordan, R., & Summers, M.
(2015). Reducing the psychological distress of family caregivers of home based
palliative care patients: longer term effects from a randomised controlled
trial. Psycho‐Oncology, 24(1), 19-24. Retrieved from:
https://onlinelibrary.wiley.com/doi/pdf/10.1002/pon.3610

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Karapetis, C. S., Stein, B., Koczwara, B., Harrup, R., Milleshkin, L., Parente, P., ... & Olver,
I. (2018). Medical Oncology Group of Australia position statement and membership
survey on voluntary assisted dying. Internal medicine journal, 48(7), 774-779.
Retrieved from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/imj.13951
Kirby, T. (2018). Australian state of Victoria passes assisted dying bill. The Lancet
Respiratory Medicine, 6(3), 182. Retrieved from:
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(18)30065-1/fulltext
Legislation.vic.gov.au. (2019). Voluntary Assisted Dying Act 2017. Retrieved from:
http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/PubStatbook.nsf/
f932b66241ecf1b7ca256e92000e23be/
B320E209775D253CCA2581ED00114C60/$FILE/17-061aa%20authorised.pdf
Pursuit.unimelb.edu.au (2017), Navigating assisted dying in Victoria. Retrieved from:
https://pursuit.unimelb.edu.au/articles/navigating-assisted-dying-in-victoria
Sheahan, L. (2016). Exploring the interface between ‘physician‐assisted death’and palliative
care: cross‐sectional data from Australasian palliative care specialists. Internal
medicine journal, 46(4), 443-451. Retrieved from:
https://onlinelibrary.wiley.com/doi/pdf/10.1111/imj.13009
Street, M., Ottmann, G., Johnstone, M. J., Considine, J., & Livingston, P. M. (2015).
Advance care planning for older people in A ustralia presenting to the emergency
department from the community or residential aged care facilities. Health & social
care in the community, 23(5), 513-522. Retrieved from:
https://onlinelibrary.wiley.com/doi/abs/10.1111/hsc.12162
Theconversation.com. (2019). Voluntary assisted dying will soon be legal in Victoria, and
this is what you need to know. Retrieved from: https://theconversation.com/voluntary-

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assisted-dying-will-soon-be-legal-in-victoria-and-this-is-what-you-need-to-know-
111836
Townsend, R. (2019). End-of-life care. Applied Paramedic Law, Ethics and Professionalism
EBook: Australia and New Zealand, 156. Retrieved from:
https://books.google.com/books?
hl=en&lr=&id=9uKiDwAAQBAJ&oi=fnd&pg=PA156&dq=australian+legislation+o
f+palliative+care&ots=KdQ2Abl8sf&sig=u1685JoRGh-s8WeVoA5pqt4o9Tw
White, B., & Willmott, L. (2018). Future of assisted dying reform in Australia. Australian
Health Review, 42(6), 616-620. Retrieved from:
http://www.publish.csiro.au/AH/pdf/AH18199
White, B., Willmott, L., & Close, E. (2019). Victoria's voluntary assisted dying law: clinical
implementation as the next challenge. Medical Journal of Australia, 210(5). Retrieved
from: https://eprints.qut.edu.au/126415/1/126415.pdf
Yoong, J., Franco, M., William, L., & Poon, P. (2018). Perspectives of cancer treatment
providers regarding voluntary assisted dying in Victoria. Internal medicine
journal, 48(7), 770-773. Retrieved from:
https://onlinelibrary.wiley.com/doi/abs/10.1111/imj.13939