Advance care planning Detering BMJ

WHAT IS ALREADY KNOWN ON THIS TOPIC
End of life care is poor and needs to be improvedFocusing on the completion of advance directives alone does not improve end of life careInvolving surrogates in discussions on advance care planning improves the likelihood that they will know the patient’s end of life wishes

WHAT THIS STUDY ADDS
Coordinated advance care planning improves end of life careAdvance care planning reduces the incidence of anxiety, depression, and post-traumatic stress in surviving relativesAdvance care planning improves patient and family satisfaction with hospital care

ACP - Anfänge, Entwicklungen und Adaptionen

Das Konzept »Advance Care Planning« entsteht im Jahr 1993 im Kontext der Diskussi­ onen über den US­amerikanischen Patient Self-Determination Act von 1990 und wird von dort ausgehend zu einem Rahmenbegriff für die Beforschung der weiteren Entwicklung (1993 auf der Squam Lake Conference). Die Idee, die Situation schwerstkranker und sterbender Patienten durch Unterstützung bei der Kommunikation zu verbessern, wurde durch die Ergebnisse der SUPPORT­Studie zwar zunächst in Frage gestellt, führte aber auch dazu, dass die Voraussetzungen für das Modell der Entscheidungsfin­ dung selbst hinterfragt wurden. Ein Ergebnis dessen war, dass das primär Autonomie­ basierte Verständnis von ACP zu einem stärker Sorge­orientierten Ansatz hin weiter­ entwickelt wurde. 

ACP in Australien

Abstract

Background: Advance care planning (ACP) is a process of planning for future health and personal care. A person’s values and preferences are made known so that they can guide decision making at a future time when that person cannot make or communicate his or her decisions. This is particularly relevant for people with dementia because their ability to make decisions progressively deteriorates over time. This study aims to evaluate the cost-effectiveness of delivering a nationwide ACP program within the Australian primary care setting.

Methods:
A decision analytic model was developed to identify the costs and outcomes of an ACP program for people aged 65+ years who were at risk of developing dementia. Inputs for the model was sourced and estimated from the literature. The reliability of the results was thoroughly tested in sensitivity analyses.

EoL Lessons from Oregon. Tolle SW Teno JM. NEJM March 16 2017.pdf

Advance care planning and the use of POLST forms is important, but if patients’ goals are not linked to actionable care plans that are support- ed by local health care systems and state regula- tion, many patients who wish to remain at home will die intubated in the hospital for all the rea- sons the current system fails them.8,9 Considerthe following composite case story, which illus- trates the complexity, breadth, and depth of sys- tems changes that are needed to ensure that patient preferences are consistently honored.

EoLLessonsOregon. Tolle SW Teno JM. NEJM 03-16-17. Suppl.Mat.

Supplementary Appendix

This appendix has been provided by the authors to give readers additional information about their work.

Supplement to: Tolle SW, Teno JM. Lessons from Oregon in embracing complexity in end-of-life care. N Engl J Med 2017;376:1078-82. DOI: 10.1056/NEJMsb1612511