Wednesday, March 30, 2016

Advance Care Planning for Seniors

There is no such thing as a living will in BC. It is a concept imported from the United States. There may be the ability to have a living will in your jurisdiction, so before assuming that you can do this check with a legal expert. However, where I live in British Columbia we have legislation that allows individuals to express their wishes, usually in writing, regarding the care they want to receive or reject.  What I am encouraging is that people have a conversation with their families or friends to discuss what should be done if, and only if, they are unable to speak for themselves

Advance care planning (ACP) begins with an in-depth discussion about your values, wishes, and beliefs. Pay particular attention to the topics that should be included in the discussion of your values, your wishes and your beliefs. The subject should be revisited from time to time because people’s views can change depending on a variety of circumstances:  health concerns, new medical procedures, new relationships. Think of your advance care planning as an organic process, as you grow your wishes, thoughts change.

Remember in most areas and in all of Canada a written Advance Care Plan is not a legal document but it is a powerful document because decision makers will have guidelines to follow should they be placed in a position of speaking for another person who is incapable of speaking for him or herself. The plan is acted upon when, and only when, you are incapable of making your own decisions.

The assumption the law takes is that most capable adults want to make their own decisions about their medical care. Under the law a health care provider must presume an adult is capable of making a decision until it is demonstrated that the person is not capable.

Sometimes it is not easy to prove that a person is incapable of making his or her own decisions. For example if a person is unconscious it is easier to determine incapability than if they are slow to speak or difficult to understand, perhaps because of a stroke or the effects of medication. However, if you cannot speak for yourself then somebody else will have to make decisions about your medical and end-of-life care
These are the tests that help medical caregivers to determine whether the individual who must be 19 years of age or older can make his or her own decisions. The first assumption must be that the adult is capable, which means that he or she demonstrates the following:
  • Understands the information being given about his or her health condition;
  • Understands the nature of the proposed health care, including the risks, benefits and alternatives; and
  • Understands that the information applies to his or her own situation.
If you are accompanying such an individual, perhaps in an emergency department, then you may need to intervene if you think the medical caregiver is rushing this procedure.  This is a crucial moment in the care process.

The real impact of advance care planning and the components that drive the subsequent care is that Decisions are going to be made, and that you can make them. or you can decide who will make them if you cannot. The most important idea is that: COME WHAT MAY, DECISIONS ARE GOING TO BE MADE.

That is why it is very important to have a Representation Agreement and you need to be sure that the representative (s) named know what your wishes are.  The Advanced Care Plan (ACP) is not the same as a Representation Agreement. A Representation Agreement indicates who you want to speak for you when you are not capable of speaking for yourself.  It is a legal document that sets out the kinds of decisions the representative may make.

An ACP provides information about the care you want to receive.  It works hand in hand with a Representation Agreement

The importance of having the right person involved requires legal documentation or in BC the Temporary Substitute Decision Makers list will be used. Who is on the Temporary Substitute Decision Makers list in BC (this may be different in your area: Spouse: married or cohabiting; may be same sex, Child (no specific order if more than one), Parent (so specific order), Sibling (no specific order if more than one), Grandparent (no specific order), Grandchild (no specific order), Anyone else related by birth or adoption, Close friend, and finally In-law (no specific order)

Decisions will be made, and if you cannot make them one of the above will, but you can give this power to someone you trust to look after your best interests. So when you start this search, here are some questions to consider
  • WHO do you approach to start the conversation?
  • HOW would you start?
  • WHAT are your values, wishes and beliefs?
  • WHERE will the plan be kept?
These suggestions about how to start the conversation may apply to the person expressing his or her own values, wishes and beliefs or by a concerned family member or friend who might be placed in a position of making the decisions. 

This can be a very tricky part of the process because very unpleasant occurrences are being contemplated, otherwise the patient would be making his or her own decisions. Deep emotions may surface and the parties involved need to structure the discussion carefully with regards to site, attendance, calling a recess, compilation of the written record, etc.

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