1. Advance Care Planning Dr Regina McQuillan FRCPI

2. What is planned? Why? Who? How? When? Where?

3. Advance Care Planning Decisions made now, in anticipation of changing health status, when it is expected the patient or decision makers will not be in a position to make the same carefully reasoned decision.

4. What is planned? Level of intervention for investigation or treatment Place of care Place of residence

5. Interventions - General Hospital transfer Intravenous antibiotics Intravenous fluids Subcutaneous fluids Gastrostomy (PEG or RIG) Ventilation

6. Interventions - Specific To address likely outcomes of particular illness

7. Motor Neurone Disease Gastrostomy Non-Invasive ventilation (NIPPY) Invasive ventilation

8. Implanted Cardiac Debrillators Switching off

9. Chronic Obstructive Pulmonary Disease Ventilation ICU

10. Dementia Tube Feeding Intravenous Antibiotics Hospital Admission

11. Why engage in Advance Care Planning? Appropriate planned decisions

12. Why engage in Advance Care Planning? No legal or ethical obligation to provide all possible treatment No obligation to provide futile treatment Patient has the right to refuse treatment, even if life prolonging.

13. Who makes the plan? Patient Doctor Multidisciplinary Team Family Hospital Team

14. Who makes the plan? No one has the legal right or responsibility to make decisions about others health

15. When should plan be made? Dependent on illness – natural history Changes in health status – eg hospital/nursing home admission Markers of deteriorating health

16. Where should plan be made? Place of care May be by joint, if patient moves from one care setting to another

17. How should plan be made? Most Important

18. How should plan be made? If patient not competent - Doctor makes decision, in best interest of the patient, taking the known wishes and values of the patient into account, following wide consultation with family and the multidisciplinary team.

19. How should plan be made? May be done in stages Rarely emergency or urgent

20. How should plan be made? Clearly documented Consider ‘transfer document’

21. How should plan be made? Reviewed as health status changes

22. Scope of Advance Care Plans Must be legal

23. Scope of Advance Care Plans Must be ethical - respect the autonomony of others - cannot require family to give all care, cannot require health care workers to treat patient unethically - respect distributive justice

24. Resources www.bioethics.ie www.resus.org/pages/dnar.htm www.endoflifecareforadults.nhs.uk