advance care planning and advance healthcare directives

ADVANCE CARE PLANNING AND ADVANCE HEALTHCARE

DIRECTIVES

Deirdre Shanagher, Marie Lynch, Dr John Weafer, Prof Willie Molloy, Dr Sharon Beatty, Dr Geraldine McCarthy, Patricia

Rickard-Clarke, Emer Begley, Esther Beck, Sarah Murphy

Hospice Friendly Hospitals Network Meeting June 9th 2016

•What would you like from todays session?

Today:• Background & Context

• The legislation – useful facts

• Key considerations to inform good practice

• Functional approach to capacity

• Decision making supports

• Advance healthcare directives

• Guidance for healthcare staff

• Case study

Video…• Thinking Ahead…

Background:

The Assisted Decision Making (Capacity) Act 2015:

• Replaces the Lunacy Regulation (Ireland) Act 1871• Includes provision for Advance Healthcare Directives which were previously legal under common law but had no legislative underpinning.• Codes of Practice/Guidelines for full implementation required• Minister for Justice will commence most of the Act• Minister for Health will commence the AHD section

Key Changes: Ward of Court system to be abolished - review of all wards

• New legal process to deal with decision-making for a relevant person in respect of a relevant decision • New - Court process • New role and office: Director of The Decision Support Service • New - Panels to be established by the Director • New - provisions for Enduring Powers of Attorneys • New - advance healthcare directives

Review of wards of court:• Within 3 years of relevant section coming into force all

current wards of court will be discharged • Court may: 1. Declare that there is no issue with the wards decision making capacity OR 2. Make one or more than one of the following declarations: • That the ward lacks decision making capacity, unless the

assistance of a suitable person as a co-decision-maker is made available to him or her, to make one or more than one decision

• That the wards lacks decision making capacity, even if the assistance of a suitable person as a co-decision-maker were made available to him or her

Key considerations to inform good practice:

1. Develop understanding of dementia

2. Become familiar with aspects of the Assisted Decision Making (Capacity) Act 2015, specifically in relation to:

• The Functional approach to capacity • Advance Healthcare directives

Functional Approach to Capacity:• Presumption of capacity

Responsibility of those questioning decision making capacity to prove there is an issue…

• Time and issue specific

Functional Approach to Capacity:

• Understand• Retain• Weigh• Communicate

Advance Healthcare Directives:

• A document where a person can write down what they would like to happen in relation to certain medical care treatments

• Only comes into force when a person loses capacity, becomes ill and the circumstances in their advance healthcare directive arise. (A record of advance healthcare directives will be held by the Director of Decision Support Services).

Issues that may be covered in an advance healthcare directive:

• Treatments that a person would refuse in the future – this is legally binding

• A request for a specific treatment. This is not legally binding but must be taken into consideration during any decision-making process which relates to treatment for the person in question if that specific treatment is relevant to the medical condition for which the person may require treatment.

What makes an advance healthcare directive legal? 1. At the time in question a person lack decision making capacity to give consent to the treatment2. The treatment to be refused is clearly identified in the advance healthcare directive3. The circumstances in which the refusal of treatment is intended to apply are clearly identified in the advance healthcare directive4. The advance healthcare directive was made voluntarily.5. The advance healthcare directive was not altered or revoked.6. The person did not do anything inconsistent with the terms of the advance healthcare directive while they had decision making capacity.

Guidance for healthcare professionals:• Always presume decision making capacity • Help the person to maximise their decision making capacity• Remember that the person with dementia can choose not to take part in the advance care planning process• Be aware of how to assess a persons decision making capacity if required to do so• Gain knowledge on what steps to take if decision making capacity is an issue• Check existing advance care plans with the person regularly for validity and applicability

Maximising decision-making capacity:• Discuss treatment options in a place and at a time when the

person is best able to understand and retain information.• Ask the person if there is anything that would help them

remember information or make it easier to make a decision; such as:• Bringing another person to healthcare meetings or • Having audio or pictorial information about their condition • Writing things down • Using simple language• Finding out how the person usually communicates• Giving the person space to think quietly• Involving others where necessary such as speech and language

therapists or psychologists

8 Tips for Effective Communication1. Adopt a person centred approach to

communication2. Connect with the person3. Consider the communication environment4. Be aware of your own communication style

and approach5. Use active listening6. Use simple language7. Focus on one question at a time8. Clarify Information and check

understandingSee G. Doc 1

Video…• Having the conversation…

Assessing decision-making capacity:• Consider what decision has to be made

• Do not discriminate

• Is there something currently happening that may temporarily affect the person’s decision-making capacity

• Consider what supports have been provided

• Consider if decision-making capacity is absent even with all practicable support

Assessing decision-making capacity:• Can the person:• Understand information relative to the decision

• Retain the information long enough to make a voluntary choice

• Use or weigh the information as part of the process of making the decision

• Communicate their decision?

If decision-making capacity is an issue:1. Support the person to be involved in the

decision-making process by engaging in capacity building and maximising.

2. Consider the level of support that the person requires to make the decision in question.

3. Seek evidence of previously expressed preferences.

4. Consider which option, including not to treat, would be least restrictive of the person’s future choices.

5. Consider the views of anyone indicated by the person. These people may be those appointed by the person to support them when making decisions.

6. A Consider involving advocacy support.

Case Study:

Guidance Document 2:

Guidance Documents:

Plan for the

probable,

work for the

possible,

hope for the

future

Acknowledgements

Thank you and QuestionsFor more information:

Deirdre ShanagherDeirdre.shanagher@hospicefoundation.ie

People with dementia and carers who have contributed and advised IHF

IHF Changing Minds Team Project and Expert Advisory and

Governance Groups Atlantic Philanthropies