Not that way: Advance Care Planning

What is Advance Care Planning?

Advance Care Planning (ACP) is a process of discussion of healthcare decisions for a patient’s future health and personal care (Table I). These plans can be very useful when the patient is unable to make or communicate their own decisions to their loved ones or healthcare team. ACP can be as simple as a chat about the patient’s end-of-life wishes with their loved ones, or involve doctors, organisations and trained facilitators. ACP is sometimes referred to as a living will, advance directive, healthcare directive or physician’s directive.

Table I

The four steps to Advance Care Planning (ACP) (adapted from Living Matters).(1)

Who needs Advance Care Planning?

ACP is for any patient who is ready. It is important because it helps patients to start the conversation and communicate their future healthcare preferences to their loved ones, next-of-kin and their attending healthcare professionals. Family physicians, with whom patients share a unique therapeutic relationship, are in the best position to introduce ACP and start the discussion with their patients.

Initiating the ACP conversation gives permission for patients to talk about end-of-life issues, and through the process, explore their options regarding healthcare. Their wishes and preferences expressed through ACP, which are preferably documented, can then be noted by their loved ones and shared with healthcare providers or teams.

How will patients know their future health states or options to make the best decisions for themselves?

ACP is meant to be an ongoing communication process that does not end after one session. The conversations can and should continue within the family and with loved ones, ACP facilitators and health professionals. These discussions can keep the patient abreast of his or her health situation and help the patient reflect, plan and make decisions for future healthcare needs.

Why must Advance Care Planning be documented?

As mentioned, ACP is a process that happens before the patient loses the capacity to make specific healthcare decisions by themselves. As an informal discussion with their loved ones may not be documented, and it is not possible to know when anyone could lose their mental capacity, documented care preferences can relieve the patient’s family of the added stress of remembering the details of these conversations in situations that can be challenging and stressful. It is preferable to have the patient’s preferences documented, as this will guide the family and clinical team in making care and treatment decisions in the best interest of the patient.

Who can be appointed as the patient’s substitute decision-maker?

The substitute decision-maker must be at least 21 years old, able to respect and honour the patient’s preferences under stressful conditions, and must have expressly accepted the role. Patients may choose a relative, best friend or anyone they think will act in their best interests when they are no longer able to do so. It will be very helpful, and it is strongly encouraged, for the appointed and willing substitute decision-maker to participate actively in the process of doing up the ACP. The substitute decision-maker can only make decisions on the patient’s behalf when the patient lacks the capacity for decision-making. If the patient still has the capacity, healthcare professionals will obtain consent from the patient.

There are two categories of substitute decision-makers:

1. Informally appointed substitute decision-maker.

   One or more person(s) can be chosen during the ACP process and the choice will be noted in the patient’s medical records. As a matter of good practice, healthcare professionals will consult the substitute decision-maker when the patient has lost decision-making capacity and there is a decision to be made, even though there is no legal requirement for them to do so.

2. Formally appointed substitute decision-maker (donee).

   One or more person(s) (donee[s]) can be formally appointed by the patient (donor), using a Personal Welfare Lasting Power of Attorney, to make healthcare decisions on behalf of the patient if the capacity to do so is lost in the future. Donees must always make decisions in the best interest of the donor, and these interests are not restricted to healthcare considerations. Healthcare professionals must, by law, consult the donee on healthcare decisions (when the patient has lost decision-making capacity), except in emergency and time-sensitive circumstances.

Advance Care Planning in Singapore

Living Matters is the local ACP framework in Singapore. It is adapted from the Respecting Choices model based in the United States.(6) There are also resources online to help clinicians, individuals or their loved ones begin the ACP process and explore the option of documenting their care preferences. The attending family physician can help to document any care preferences and decisions that their patients may express and share these with the family or other clinicians helping in the medical care of the patient, if and when the need arises.

For patients with more complex conditions, ACP discussions may need to be facilitated by a trained healthcare professional. These facilitators are currently available in most Singapore public hospitals. ACP is not a legal document; therefore, there is no need for the presence of lawyers for its discussion or documentation.

ACP is often confused with Advance Medical Directive or the writing of a will, although these components may be discussed as part of the ACP conversation. Table II briefly summarises some of these terms for clarity.

Table II

Differences between Advance Care Planning, Advance Medical Directive and Lasting Power of Attorney (adapted from Living Matters).(1)

Will and testament

A will and testament is a legal instrument made by a person (testator) that states how the testator’s property should be managed and distributed after the testator’s death. A will takes effect only after the testator’s death and not when they are still alive but not able to make their own decisions.