Advance care planning in an aging population

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People think their doctors should play a bigger role in advance care planning, according to new research.

Most GPs believe that patients should start advance care planning in their late 50s.


An article exploring cognitive and behavioral biases in advance care planning (ACP), published in Palliative care and social practicefound that only 14% of the Australian population currently has an advance health directive.


And for Dr Stephen Whyte, behavioral economist at Queensland University of Technology and co-author of the paper, the issue will become increasingly important as the Federal Government reports that the number of Australians aged 65 years and older has fallen from 8.3% of the total population in 1970 to 16% in 2020, with this figure expected to reach between 21 and 23% by 2066.


“The benefits are clear. For the affected person, it can improve the quality of their end-of-life experience and ensure that their wishes are explicitly met, as well as relieve stress and anxiety for loved ones,” he said.


“It can also significantly reduce the psychological, emotional, administrative and economic burden on healthcare professionals and systems.”


Research has found that one of the main reasons ACP adoption is so low is lack of patient knowledge.


Associate Professor Joel Rhee, chair of the RACGP Special Interests in Cancer and Palliative Care, agrees that ACP is not widely and well understood. He believes GPs have an important role to play in introducing the concept to their patients.


“GPs can help answer many questions people might have,” said Associate Professor Rhee newsGP.


“Some of the questions people usually think about when doing advance care planning include what happens when they get really sick, what is the meaning of CPR [cardiopulmonary resuscitation] and life-saving treatment. These are essential aspects of health [of ACP].


“GPs can also provide advice on the process and the legal side of things.


“For example, explaining what an advanced care directive is and how it is different from advance care planning and explaining what an enduring guardian or responsible person is.”


The researchers collected data from 1,253 members of the Australian public aged between 18 and 80, as well as 117 nurses and general practitioners.


“Previous research in this area has primarily focused on samples from critically ill and/or elderly populations, and has not explored the role of bias in decision-making,” Dr. Whyte said.


“Our study provides new and novel empirical findings from both frontline healthcare professionals and potential future patients regarding ACP communication and preferences.


“Triggers for engaging in a discussion about ACPs are usually related to a significant, new or ongoing health issue.


“Interestingly, our study shows that most people and GPs consider it appropriate to start such a discussion in their late 50s. Nurses, on the other hand, see it as a priority early in their quarantine, likely because they are most involved in the day-to-day provision of end-of-life care.


Associate Professor Rhee agrees that, in an ideal world, more patients would start thinking about ACP earlier, but he admits there are resource constraints which mean this is not feasible.


“If there were a lot of GPs who could give advice to everyone, including perfectly healthy 25-year-olds, then I think advance care planning and advance care directives should recommended to everyone,” he said.


“But this is one of those resourcing situations, so it makes sense that we GPs think about facilitation with those who could benefit the most.”


There is no one-size-fits-all approach to PPS; however, GPs should consider initiating ACP discussions with some patients more than others, says Associate Professor Rhee.


“Care really needs to be personalized and tailored, and GPs are very well placed to be able to do that because they know their patients very well,” he said.


“You might have a patient who has health issues, chronic illness or advanced disease; in this situation, the possibility of them becoming very ill in the future is increased and it makes sense for that person to think about these issues sooner.


Associate Professor Rhee also points out that patients can have very strong or specific opinions about end-of-life care.


“For example, a person of faith who is a Jehovah’s Witness…could refuse treatment involving a blood transfusion,” he said.


“Obviously we can’t assume the patient will have these views, but it’s important to check with the patient and, because it’s such a rare view, it’s worth that person thinking about their views. opinions and preferences and plans to document them.


“And advanced age is, of course, another factor.”


Associate Professor Rhee stresses the importance of open and frank discussion between GPs and their patients and, if they choose to include them, their families and loved ones.


“These discussions often reinforce the existing relationship, which is why the discussions are often more important than the results, which can be the directive or the documentation,” he said.


“Having these discussions helps build trust, improves understanding and strengthens relationships.”



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