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Push for advanced care plan law

There is growing pressure for a nationally consistent approach to end-of-life planning to protect patients, families and healthcare workers, reports Darragh O Keeffe.

Delivering advanced care planning (ACP) to every aged care facility in Australia would save about $330 million from the health budget each year, an expert has said.

Associate Professor Bill Silvester, intensive care specialist at Austin Hospital in Melbourne and director of the Respecting Patient Choices program, said that not only does ACP save the health system money it also results in better end-of-life care and less stress and anxiety for family and relatives.

ACP was important because 85 per cent of people die after a chronic, often lengthy illness, not a sudden event. Nearly half are not in a position to make their own decisions when near death, and family are unlikely to know their views without a discussion. Doctors, uncertain about what to do, and who have to make a decision, will often treat aggressively. And, many people will be kept alive under circumstances that are not dignified, frequently suffering and in a way that they would not have wanted, he said.

Silvester was part of a research team which produced a landmark study, published in the British Medical Journal in 2010 and quoted widely around the world, most recently by Barack Obama’s administration.

The trial involved 309 eligible participants (competent and aged over 80) who were roughly split into an intervention group, which availed of ACP, and a control group, which did not.

Some 56 patients (29 intervention group; 27 control group) died within six months. Patients’ wishes for end-of-life care were known and respected for 86 per cent of those in the intervention group, compared with just 30 per cent of those in the control group.

Further, no one from the intervention group died in the ICU, having expressed their wish not to, while four patients in the control group did.

Silvester said the highlight of the study was the positive impact ACP had on the relatives.

Using two different scores the researchers found that not only was the prevalence of post-traumatic stress much higher in relatives of patients in the control group, four had symptoms high enough to warrant medical treatment six months out from the death. Similarly, only families of patients in the control group presented with depressive symptoms.

Speaking to aged care providers at the recent Aged and Community Services Association NSW/ACT conference, Silvester also outlined the results of the implementation of the Respecting Patients’ Choice program in Melbourne facilities in 2004 and 2005.

Of 1100 residents introduced to the program, just 2 per cent refused further discussion. During the two-year evaluation, 16 per cent of residents died; 58 per cent had been introduced to the program and, of these, 89 per cent had advance care plans. Of those with plans, 96 to 100 per cent of their wishes were respected at end of life.

Importantly, residents were much more likely to die in hospital without advance care planning. Of those who had not undergone ACP almost half were transferred to hospital to die on a trolley or in a ward, compared with 20 per cent of those who did have an ACP.

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