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An Explanation of Advance Care Directives

CPDTime.
4m

Published: 01 June 2020

When the potential outcome for a patient is poor, there may be confusion about the interventions that should be made if the patient is not able to make a sound decision for themselves.

An advance care directive is a critical form of documentation that communicates the patient’s instructions and wishes, taking the burden of decision-making off loved ones.

In the case of sudden deterioration, it is essential to know where a patient’s advance care directive can be found and understand how it works.

What is an Advance Care Directive?

An advance care directive is a legally binding document that outlines a patient’s directions and/or preferences in regards to medical treatment. It is used in the event of incapacitation where the patient does not have the decision-making capacity to communicate their wishes (Public Advocate Victoria 2018).

An advance care directive is written by the patient (Advance Care Planning Australia 2017).

When a patient does not have decision-making capacity, healthcare providers will consult the patient’s advance care directive and use it to guide clinical decisions (Victoria DoH 2015).

Although advance care directives are part of end-of-life care, they are an important document for everyone to consider regardless of their current medical condition - emergencies can strike at any time (MedicAlert Foundation 2018).

Ideally, an advance care directive should be completed before the patient becomes unwell so that their treatment plan and wishes are clear if care escalates.

Any person over the age of 18 with decision-making capacity is able to write an advance care directive (Australian DoH 2019). A patient can also write a new advance care directive and replace their existing one at any time (Advance Care Directives SA 2017).

advance care directive writing
An advance care directive is a legally binding document that outlines a patient’s directions and/or preferences in regards to medical treatment.

What is Decision-Making Capacity?

All adults should be assumed to have decision-making capacity unless proven otherwise (ELDAC 2018).

Generally, in order for a patient to have decision-making capacity, they must:

  • Be able to comprehend and retain the information needed to make a decision. This information includes information about the treatment, alternatives, consequences and risks; and
  • Be able to use and evaluate the information as part of making a decision.

(ELDAC 2018)

While this is the definition of capacity under common law, each state and territory may have additional requirements and specific tests to determine a patient’s capacity (ELDAC 2018).

What Does an Advance Care Directive Contain?

A patient may choose to write an instructional directive, values directive or both in their advance care directive:

  • An instructional directive gives consent or refusal to medical treatments specified by the patient. These directions are legally binding and must be followed by healthcare staff.
  • A values directive lists values and preference of the patient that must be taken into consideration by the medical treatment decision-maker. The patient may list their preferences, life goals and preferred outcomes.

(Public Advocate Victoria 2018; Advance Care Planning Australia 2017)

The patient may also choose to appoint one or more substitute decision-makers in their advance care directive. These specified decision-makers will be granted the legal authority to make decisions on behalf of the patient if they become unable to do so themselves (Victoria DoH 2018).

advance care directive substitute decision maker
The patient may choose to appoint one or more substitute decision-makers who will be granted the legal authority to make decisions on behalf of the patient if they become unable to do so themselves.

Why Write an Advance Care Directive?

A global study spanning two decades, 10 countries and 1.2 million patients found that 33% of older end-of-life care patients were receiving non-beneficial, invasive and unwanted interventions in their last two weeks of life (UNSW 2016).

An advance care directive empowers the patient to inform the treatment they receive and communicate their wishes for the future rather than relying on loved ones to decide. It provides them peace-of-mind that their preferences will be respected in the event of incapacitation and prevents them from suffering unwanted interventions (MedicAlert Foundation 2018; Advance Care Directives SA 2017).

How do you make an Advance Care Directive?

This will depend on the patient’s state or territory of residence, as each has individual forms and requirements. These can be found on the Advance Care Planning Australia website.

Legislation

Although the legislation and requirements for advance care directives differ between states and territories, the National Advance Care Directives Framework (2010) outlines the goals each jurisdiction should strive for in developing policy and practice.

Advance care directives are governed by the following state and territory legislation:

Advance care directives are recognised by common law in New South Wales and Tasmania (ELDAC 2020).

Consent and Refusal

Under Australian legislation and common law, all patients with decision-making capacity have the right to make informed decisions about medical treatment and must give consent to any treatment they receive (Haysom 2019).

Informed consent means that:

  • The patient has decision-making capacity;
  • The patient consents voluntarily (without coercion, manipulation or undue pressure); and
  • The patient consents to the same treatment that is given.

(ELDAC 2018)

Patients with decision-making capacity also have the legal right to refuse any medical treatment, even if it will result in death. A patient can refuse treatment for any reason and this decision must be followed by healthcare staff; overriding this is a violation of the patient’s bodily integrity and the offending healthcare worker may be subject to civil or criminal law (QUT 2020).

By writing an advance care directive, a patient is able to specify treatments they consent and/or refuse to, and these instructions will be adhered to if the patient’s decision-making capacity is lost.

advance care directive hospital
All patients with decision-making capacity have the right to make informed decisions about medical treatment and must give consent to any treatment they receive.

Where Should an Advance Care Directive be Stored?

  • With the patient;
  • At the patient’s hospital;
  • At the patient’s residential aged-care facility;
  • With the patient’s general practitioner and treating specialist;
  • On My Health Record;
  • With any substitute decision-makers;
  • With the patient’s family and/or close friends.

(Advance Care Directives SA 2017)

Conclusion

When working with patients, It is crucial to establish whether they have an advance care directive, where it is located and when it should be used.

Additionally, you must understand and adhere to patients’ legal and ethical rights in regards to consent.

Additional Resources


References

Test Your Knowledge

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Question 1 of 3

Jim has been in a serious accident and is taken to hospital, where medical staff are suggesting a treatment that would be beneficial to him. Jim is accompanied to the hospital by his wife Mary, who is listed as a substitute decision-maker on his advance care directive. Jim is currently awake but highly confused and having difficulty understanding what the medical staff are telling him. Who has the authority to decide whether Jim receives the treatment?

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