“A `good death` helps maintain the organization, while `bad` deaths consume resources and cause emotional stress on employees and families. The ACP can therefore benefit not only patients with an incurable disease, but also the health institution by systematizing and promoting the “good death”. [Art. 26] . Some panelists felt that conversations were the most important, while others emphasized documentation. There have been discussions that some people may want to document their desires without having a conversation, while others may face problems related to distrust of the health care system or have limited reading or language skills that prevent them from recording their wishes in a legal document. The Panel decided that the documentation of ACP discussions and/or the completion of legal documents is necessary to ensure that medical care is in line with the patient`s preferences. Because of their importance, the ongoing discussions and documentation have been included as strategies to support adults in ACP countries. It is expressly emphasized that conversations in the medical record must be documented in order to provide context on patients` decisions, even though different jurisdictions have different international laws regarding the use of oral living wills.23 Singer PA, Martin DK, Lavery JV, Thiel EC, Kelner M, Mendelssohn DC. Rethinking advance planning from a patient perspective. Arch Intern Med. 1998;158:879–84 doi.org/10.1001/archinte.158.8.879.
This definition complements several previous ACP descriptions,4–8 a recently published IOM report,12 a Canadian conceptual framework for end-of-life communication,5 and more recent CMS billing statements.3,13 Concepts similar to previous descriptions include conceptualizing the CPA as a process that unfolds over time; whereas the ACP States may begin at any age and at any stage of life; whereas the ACP States should be reviewed and expanded in the light of changing health conditions; and that discussions and documentation are important. Lumberjack ET, Lee S, Chilson K, Back AL, Block S, Loberiza FR. Prospective care planning for hematopoietic cell transplant patients and bereaved families. Marrow. 2014;49:1317–22 doi.org/10.1038/bmt.2014.152. Panelists noted several tensions with respect to ACP concepts, for example: whether the definition should focus on conversations versus written living wills; patients` values in relation to treatment preferences; current joint decision-making in relation to future medical decisions; and who should be involved in the process. The committee came up with a final consensus one-sentence definition and accompanying goal statement: “Advance care planning is a process that helps adults, at any age or stage of health, understand and share their personal values, life goals and preferences for future medical care. The goal of advance planning is to ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illnesses. The group also outlined strategies for the best possible support for adults in ACP countries.
A multidisciplinary delphi panel has developed a consensus definition of THE CPA for adults that can be used to support the implementation and measurement of ACP clinical, research and policy initiatives. In Principles for Patient and Family Partnership in Care, ACP cites growing evidence that patient-family partnerships in care can improve health outcomes, efficiency of practice, and patient and job satisfaction. Patient- and family-centred strategies have been shown to reduce the use of health care resources, result in fewer referrals and diagnostic tests, and reduce health care costs. Sellars M, Clayton JM, Morton RL, Luckett T, New Year`s Eve W, Spencer L, Pollock CA, Walker RG, Kerr PG, Tong A. An interview study on patient and care perspectives on advance care planning in the ESRD. At J Kidney Dis. 2018;71:216-24 doi.org/10.1053/j.ajkd.2017.07.021. In the scientific literature, five different objectives of the CPA prevail: respect for the individual autonomy of the patient, improvement of the quality of care, strengthening of relationships, preparation for the end of life and reduction of overtreatment. Negotiating which objective prevails in a particular situation can show which results are compatible with the chosen objective and which risks must be taken into account. The definition of the underlying objectives can guide the debate on the definitions, methods and preferred outcomes of the ACP States.
Johnson S, Butow P, Kerridge I, Tattersall M. Advance Care Planning for Cancer patients: a systematic review of perceptions and experiences of patients, families, and healthcare providers. Psycho-oncology. 2016;25:362–86 doi.org/10.1002/pon.3926. This definition has several limitations. First, this definition does not include children, parents, guardians or adults who do not have the capacity to make decisions. In addition, it does not yet meet the standards of use in the general public. In addition, all Delphi panels are inherently self-selective, which can lead to choice and information biases. In particular, a subgroup of panelists participated in five Delphi rounds. However, the entire group first identified the issues that required clarification for the subgroup during the first 3 rounds, and the entire group was able to reconsider and provide feedback and accept the final definition after reviewing the subgroup. In addition, panel members came from only four countries (mainly in the United States) and four disciplines; As a result, this definition may lack generalizability. In addition, we used a modified Delphi method and therefore cannot report the ranking data.
We recognize that the initial disagreement on an ACP definition is likely due in part to a lack of evidence as to what constitutes clinically significant ACP. With ongoing research, we recognize that this definition will evolve over time. For example, forensic partnerships can help extend ACP beyond medical planning.30,31 Although panelists felt that definitions and objectives could not be separated from AKP`s adult support strategies, these proposals do not constitute a rigorous systematic review of the literature. Research on these strategies is needed. Song MK, Ward SE, Lin FC, Hamilton JB, Hanson LC, Hladik GA, Fine JP. Racial differences in the outcomes of an advance planning intervention for dialysis patients and their surrogate mothers. J Palliat Med. 2016;19:134-42 doi.org/10.1089/jpm.2015.0232. `( . ) Akp can be beneficial for residents` relatives as it can facilitate their decision-making. While the well-being of loved ones and confidence in their role as substitute decision-makers may be important outcomes of the CPA, patient values and preferences should be the focus of attention.
`[Article 3] . Together, patients or their surrogate decision-makers, family members and healthcare professionals make health care decisions that are in the best interests of the patient. Quotes such as “improving end-of-life care” and “a good death” have often been found, meaning there is a supposed consensus on what “quality end-of-life care” or “a good death” is. Discussions are about personal values and concerns, not care decisions. In this way, patients and their loved ones feel able to manage and feel relief from anxiety, depression and stress. Similarly, it can be argued that a living will should be respected because what the patient has already said she wants is what she really wants now, even if she is too unable to know what she wants now. [Art. 50] . In addition, some patients prefer to rely on God or accept the mandate of nature. They don`t want their treatments to be limited by doctors. If reducing overtreatment is the underlying goal, patients` interest in engaging in CPA may decrease. It could even lead to mistrust of health professionals and the health system.
Schwartz CE, Wheeler HB, Hammes B, Basque N, Edmunds J, Reed G, Ma Y, Li L, Tabloski P, Yanko J. UMass End-of-Life Working Group Early intervention in planning end-of-life care with ambulatory geriatric patients: Results of a pilot trial. Arch Intern Med. 2002;162:1611-doi.org/10.1001/archinte.162.14.1611 8. “Another concern might be that financial resources are not wasted to extend a very low quality lifespan. ( . ) Decisions to forego expensive treatment that brings few end-of-life benefits should be easier if the patient has explicitly rejected them. [Art.
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