Posted: July 4th, 2024

Advance Care Planning for Individuals with Chronic Health Conditions

Advance Care Planning for Individuals with Chronic Health Conditions

The process of advance care planning (ACP) is crucial for individuals with chronic health conditions to ensure their future medical care aligns with their values and preferences. This essay examines the case of Bob, a 58-year-old man diagnosed with Amyotrophic Lateral Sclerosis (ALS), to discuss how a registered nurse can facilitate the ACP process.

Initiating the ACP Conversation

Several factors in Bob’s case indicate the appropriateness of initiating an ACP conversation. His recent diagnosis of ALS, a progressive neurodegenerative disease, coupled with his expressed concerns about future treatment options, particularly regarding mechanical ventilation, serve as clear prompts for ACP discussion (Lum et al., 2019). Additionally, Bob’s recent hospitalisation due to aspiration pneumonia highlights the potential for rapid health deterioration, further emphasising the need for timely ACP.

The timing of this conversation is critical. It should occur when Bob is medically stable and in a comfortable environment, such as during a home visit. The nurse should ensure Bob has had sufficient time to process his diagnosis but before his condition significantly impairs his decision-making capacity (Zwakman et al., 2018). It is essential to approach the topic sensitively, acknowledging Bob’s expressed worries and using them as a starting point for discussion.

Benefits and Barriers to ACP

Engaging in ACP offers several benefits for Bob. It provides an opportunity to clarify his treatment preferences, potentially reducing future conflicts between his wishes and those of his family. ACP can also alleviate anxiety about the future by giving Bob a sense of control over his care (Jimenez et al., 2018). Furthermore, it can facilitate communication between Bob, his healthcare providers, and his family, ensuring all parties understand his wishes.

However, potential barriers to ACP exist. Bob’s wife Margaret’s desire for life-prolonging treatments may conflict with Bob’s preferences, potentially causing emotional distress. Bob’s own uncertainty about his wishes (“I don’t know what to do”) may also hinder the process. Additionally, the progressive nature of ALS might create time pressure, making it challenging to engage in thorough discussions before cognitive impairment occurs (Zwakman et al., 2018).

Documenting Values, Preferences, and Beliefs

As a registered nurse, documenting Bob’s values, preferences, and beliefs is crucial for effective ACP. This process involves conducting in-depth conversations with Bob to explore his understanding of his condition, his goals for care, and his views on quality of life. The nurse should use open-ended questions and active listening techniques to encourage Bob to express his thoughts and concerns fully.

The information gathered should be documented clearly and concisely in Bob’s medical record, using standardised ACP documentation forms where available. This documentation should include specific details about Bob’s preferences for life-sustaining treatments, pain management, and end-of-life care. It is essential to use Bob’s own words where possible to accurately capture his values and beliefs (Sudore et al., 2017).

To ensure this information is shared with the multidisciplinary team, the nurse should:

1. Update Bob’s electronic health record with the ACP documentation.
2. Discuss the ACP outcomes during multidisciplinary team meetings.
3. Ensure a copy of the ACP document is available in Bob’s home for visiting healthcare professionals.
4. Encourage Bob to share his ACP document with his family members.

Appointing a Medical Treatment Decision Maker

Under the Medical Treatment Planning and Decisions Act 2016, Bob has the right to appoint a medical treatment decision maker. This person will make medical decisions on Bob’s behalf if he loses decision-making capacity. The nurse should explain this role to Bob and discuss the importance of choosing someone who understands his values and can advocate for his wishes.

To decide whom to appoint, Bob should consider:

1. Who knows him best and understands his values and preferences?
2. Who is likely to be available and willing to make difficult decisions under pressure?
3. Who can communicate effectively with healthcare providers and family members?

Given Bob’s family situation, potential candidates might include his wife Margaret or one of his adult daughters. However, the nurse should emphasise that the choice is entirely Bob’s and should reflect who he believes will best represent his interests (White et al., 2014).

Reviewing the Advance Care Plan

Bob’s advance care plan should be reviewed regularly to ensure it remains current and reflective of his wishes. Specific situations that would prompt a review include:

1. Changes in Bob’s health status or functional abilities.
2. After each hospital admission or significant medical event.
3. If Bob expresses a change in his care preferences.
4. At regular intervals (e.g., every 6-12 months) even without significant changes.

The nurse should emphasise to Bob and his family that the ACP is a dynamic document that can be updated as his condition progresses or his views change (Sudore et al., 2017).

Accessing and Enacting the Advance Care Plan

Bob’s advance care plan would be accessed and enacted when he loses the capacity to make or communicate his own medical treatment decisions. This could occur due to the progression of his ALS, during a medical emergency, or if he develops cognitive impairment.

In such situations, healthcare providers would refer to Bob’s advance care plan to guide treatment decisions. The appointed medical treatment decision maker would be consulted to interpret Bob’s wishes in the context of the current medical situation. It is crucial that all healthcare providers involved in Bob’s care are aware of the existence of his advance care plan and can access it quickly when needed (Jimenez et al., 2018).

In conclusion, facilitating advance care planning for Bob requires sensitivity, clear communication, and a thorough understanding of the legal and ethical frameworks governing ACP. By addressing each stage of the ACP process thoughtfully, the registered nurse can help ensure that Bob’s future care aligns with his values and preferences, even as his condition progresses.

References:

Jimenez, G., Tan, W.S., Virk, A.K., Low, C.K., Car, J. and Ho, A.H.Y., 2018. Overview of systematic reviews of advance care planning: summary of evidence and global lessons. Journal of Pain and Symptom Management, 56(3), pp.436-459.

Lum, H.D., Sudore, R.L. and Bekelman, D.B., 2019. Advance care planning in the elderly. Medical Clinics, 103(5), pp.791-801.

Sudore, R.L., Lum, H.D., You, J.J., Hanson, L.C., Meier, D.E., Pantilat, S.Z., Matlock, D.D., Rietjens, J.A., Korfage, I.J., Ritchie, C.S. and Kutner, J.S., 2017. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. Journal of Pain and Symptom Management, 53(5), pp.821-832.

White, B., Tilse, C., Wilson, J., Rosenman, L., Strub, T., Feeney, R. and Silvester, W., 2014. Prevalence and predictors of advance directives in Australia. Internal Medicine Journal, 44(10), pp.975-980.

Zwakman, M., Jabbarian, L.J., van Delden, J.J., van der Heide, A., Korfage, I.J., Pollock, K., Rietjens, J.A., Seymour, J. and Kars, M.C., 2018. Advance care planning: A systematic review about experiences of patients with a life-threatening or life-limiting illness. Palliative Medicine, 32(8), pp.1305-1321.

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Assessment task 3: Take Home Examination
Assessment Summary
Task type: Take home exam/ written assignment
Task length: (+/-10%)
Weighting: 40%
Due Date/Time: Multiple due dates
A penalty of 10% per day will be applied for every day after the due date.
Submission: Submit as a .docx file via this page.
Task purpose:
For this assessment task, you will review a case study and present an essay discussing how the registered nurse (RN) may facilitate the process of advance care planning for people with chronic health conditions. You will explain multiple steps of the advance care planning process. You will apply these steps to Bob’s case. Your ability to explain the important considerations in each step of the advance care planning process will help you support people to make informed decisions about their future care, which align with their preferences and values.
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Learning Outcomes:
By the end of the task, you will be able to:
• Integrate the core principles covered in the subject and its pre-requisites, to develop practice knowledge and skills to support comprehensive patient assessment and monitoring across the lifespan while maintaining cultural awareness, respect and sensitivity.
• Discuss the ethical and legal principles of end-of-life support and enduring powers of attorney as they apply to nurse-patient interactions and respecting cultural values and beliefs.
• Discuss the process of advance care planning, as underpinned by the Medical Treatment Planning and Decisions Act 2016.
• Outline how decision-making capacity is determined.
• Discuss review and activation of an advance care plan.
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Task Description:
For this assessment task, you will be required to review a case study and present an essay discussing how the registered nurse may contribute to facilitating the process of advance care planning for people with chronic health conditions.
The National Framework for Advance Care Planning Documents (2021) recognises advance care planning as a “voluntary and beneficial process, in which individuals can think and plan for their future care; that is, care that is required during periods where they cannot make contemporaneous decisions for themselves. It can bring to light an individual’s values, beliefs, and preferences” (p6).
The National Framework for Advance Care Planning Documents (2021) considers three iterative stages of advance care planning:
• Having the advance care planning conversation
• Making an advance care planning document
• Accessing and enacting an advance care planning document
Further, Medical Treatment Planning and Decisions Act 2016 provides a single framework for medical treatment decision making for people without decision making capacity that ensures that people receive medical treatment that is consistent with their preferences and values.
Part 1: Familiarise yourself with the three iterative stages of advance care planning and think about how these might apply to Bob’s situation. Review the medical treatment decision making act and consider how the act might enable Bob to able to create a legally binding advance care directive. Based on the three iterative stages of advance care planning, you are required to write an essay discussing how you would address each stage in relation to Bob’s case. To do this, you will need to read widely by accessing journal articles, government documents and clinical guidelines (if relevant). Your essay should be your own work with the discussion supported by the citation of contemporary evidence from your research.
Part 2: Review the case study of Bob
Please watch this short introduction to Bob, and review Bob’s case as follows.
Bob is a 58 year old male, who was diagnosed with Motor Neuron Disease- Amyotrophic lateral sclerosis type (ALS) 12 months ago. Bob lives at home with his wife Margaret in a suburb of Melbourne. They have two daughters aged 31 and 28 who live close by and are supportive, although they are also busy with their own young families.
Bob was working as an electrician until 12 months ago when he received his diagnosis. Margaret works part-time as a midwife at a local maternity hospital. Since Bob’s diagnosis, Margaret has had to take an increasing amount of time off work to support him at home and to attend medical appointments. Bob and Margaret are beginning to experience significant financial pressure due to these circumstances.
Bob recently had a hospital admission following a mechanical fall, where he was also found to have aspiration pneumonia secondary to dysphagia. Bob was treated with antibiotics and reviewed by a speech pathologist during his admission. Subsequently, Bob was referred to outpatient services (primary healthcare nursing, PT, OT, SP and SW) for therapy and supports to improve physical and social functioning, as well as a case conference family meeting to develop a care plan once all disciplines are engaged and have completed a review. You are a primary healthcare nurse, and you have access to Bob’s MyHealth record.
You are visiting Bob for a review and to plan for his upcoming case conference. As you start talking to Bob, he tells you “I’m worried about what will happen to me and I don’t want to end up with a breathing tube”. Bob then goes on to tell you “Margaret is keen for me to have any treatment that keeps me alive for longer, but I’m worried what that might look like and I don’t know what to do”.
Part 3: Considering the information contained in Bob’s case, write an essay addressing the following points:
1. Based on the information in Bob’s case, what would prompt you to initiate a conversation about advance care planning with Bob? Discuss important considerations for appropriate timing of this conversation with Bob.
2. What are the benefits of Bob engaging in advance care planning, and what might be some of the barriers?
3. How would you as the registered nurse document Bob’s values, preferences, and beliefs, and ensure these could be shared with other members of the multidisciplinary team?
4. Discuss how Bob would appoint a medical treatment decision maker, and how we might decide who to appoint.
5. When might Bob’s advance care plan be reviewed?
6. In what situation would Bob’s advance care plan be accessed and enacted?
(Approximately 250-300 words each)
Proofread your essay before submission and ensure you have cited all sources of information in the body of your essay (in-text) and reference list according to APA 7th ed. The APA 7th ed. guidelines can be found via the University of Melbourne’s library’s home page or by following direct link: https://library.unimelb.edu.au/recite/referencing-styles/apa7.
Ensure you use relevant evidence from a wide range of sources and that all references are cited accurately in your assignment and in the reference list, using APA (American Psychological Association) 7th edition citation conventions.
Use primary sources that are peer reviewed and with the most current information whenever possible.
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Assessment criteria:
Your work will be assessed on:
• Your analysis and explanation of the benefits for advance care planning for Bob, and potential barriers to the process of advance care planning for Bob.
• Your ability to consider the timing of advance care planning conversations with Bob.
• Your identification and exploration of documentation required during the process of advance care planning.
• Your description of the process Bob would engage in, when selecting a medical treatment decision maker
• Your ability to consider when Bob’s advance care plan might be reviewed.
• Your identification of when Bob’s advance care plan would be accessed and enacted.
• The clarity, structure and organisation of your writing and your use of discipline-specific language
• How well you use high quality references to support your writing.
• How well you adhere to APA 7th edition referencing conventions.
________________________________________
Notes regarding the rubric below:
* Issues with task length: section is either clearly over length, ie more than 10% outside of expectation.
** Non-distracting errors are those which do not impede the flow of reading or deviate the reader from the message by their nature or frequency.
*** Minimum number of references required is stated in the task brief. If minimum number of references has not been met, but the work is otherwise satisfactory in the Evidence of research and citation criterion, the maximum result attainable is 2.5.

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Tags: 2000 words assessment task, Advance Care Planning for Individuals with Chronic Health Conditions, Assessment task 3: Take Home Examination