This video is designed to help you
understand the legal framework of
advance care planning
including enduring powers of attorney
for personal care and welfare
and advance directives.
Advance care planning is a process of
shared discussion for future health care.
It involves an individual whānau and
their health care team.
Advance care planning is an opportunity
for a person to develop and express
their preferences
for future care based on their values,
beliefs, concerns
hopes and goals. The focus is on giving
people the opportunity to say what care
and treatment they do
and don't want now and in the future as
well as what they would like to see
happen when they are dying
and after they die.
The person is encouraged to capture this
in an advance care plan.
This plan is aimed at supporting people
and their families
to get onto the same page about what is
most important to the person
and to ensure their health care team use
that information
to support shared decision-making in the
future.
It can help a person and their whānau
clarify differing views
improve understanding of treatment
options, feel more in control
and positively enhance a person's hope
in the face of progressive illness.
Advance care planning has also been
shown to reduce stress, anxiety and
depression for whānau
after a person has died. For health care
staff the process of advance care
planning helps to develop and deepen
relationships
between your health care team, the person
and their whānau.
Evidence shows that advance care
planning supports a substantial
reduction in unwanted and unwarranted
treatments for people.
This leads to fewer and shorter hospital
admissions
and improved quality of life for the
person in care.
Ideally this process of planning starts
before the person becomes unwell
and continues throughout their lifetime.
An advance care plan has a section for
a person to say who they want to be
involved in decision-making.
People named in the advance care plan
will be included in conversations about
what care and treatment to provide
wherever possible by the health care team.
These people will not be able to consent
or refuse treatment for the person
unless they are the person's activated
enduring power of attorney for personal
care and welfare.
Enduring powers of attorney for personal
care and welfare
cover the person's health accommodation
and associated care decisions.
There can only be one person designated
for this role and the responsibility is
activated
only if a medical professional or the
family court decides the person is not
competent
as defined by the protection of personal
property and rights act of 1988.
The overriding consideration of the
attorney is to promote and protect the
person's welfare and best interests.
They can make decisions on the personal
care and welfare matters
only as specified in the EPA and the Act
but there are limits on the attorney's
powers. The attorney cannot refuse
consent on behalf of the person to have
medical treatment
that might save their life. If a person
has a strong preference not to receive a
specific
life-sustaining treatment they should
capture that in an advance directive
so that the person's attorney will not
need to be asked to consent.
An advance care plan has legal standing
and clinicians are required to take it
into consideration
when determining treatment options.
Rights and corresponding obligations for
clinicians
are set out in the code of health and
disability consumers rights.
These include the right to dignity and
independence
the right to services of an appropriate
standard and the right to make an
informed choice and give informed
consent.
An advance care plan can and often does
include an advance directive.
An advance directive is consent or
refusal of specific treatment that may
be offered in the future when the person
no longer has capacity.
It doesn't come into play until the
specific treatment is offered and the
person is unable to consent themselves.
Advance directives are generally valid
when they are created by a person who
has mental capacity to make the
directive,
the directive is made freely and without
undue influence,
the person intends to apply it to the
current circumstances
and, at the time of making it, the person
understood the benefits,
risks and consequences of consenting to
or refusing the specific treatment.
Valid advance directives are legally
binding. This applies even if a refusal
of treatment contained in the advance
directive
is not what is in the person's best
interest from the clinician's
perspective.
Just like when a person is competent and
refuses a treatment
we cannot force the treatment onto that
person.
An advance directive does not need to be
signed or dated
and in fact can even be verbal, however
having an advance directive in writing,
signed and dated by the person and the
supporting clinician
is good practice. The national advance
care plan template contains a section
for advance directives. Providing the
directive as part of an advance care
plan
will give the clinician more information
and context
to understand the advance directive and
assess its validity.
Depending on the situation there are a
series of steps to offering treatment
and seeking consent. First a treating
clinician determines what treatment to
offer based on the person's current
condition,
other health issues and risk. They take
into consideration the person's
goals, priorities and preferences.
Ideally the person has captured this
information into their advance care
plan.
Just because a person has requested
specific treatments or stated a
treatment preference
does not obligate the treating clinician
to offer these.
If the person is able to they will be
asked to consent to the treatment
offered before the clinician proceeds.
If the person is unable to consent then
the treating clinician should determine
whether the person has already consented
in the form of an advance directive,
if there is a valid advance directive that
applies to the specific treatment
offered
the consent or refusal contained in the
advance directive
is legally binding. If there is no
advance directive
or the treating clinician has reasonable
grounds to doubt the validity of the
advance directive
the clinician must look for anyone else
who has the power to consent on behalf
of the patient.
This would be an activated enduring
power of attorney or court appointed
welfare guardian.
It's important to know that no one else
has the legal right to consent or refuse
treatment
and that an enduring power of attorney
cannot refuse life-sustaining treatment.
If there is no one with the power to
consent on the patient's behalf
the treating clinician is obligated to
take into consideration
any advance care plans and talk to
whānau and other clinicians
about what the patient would have wanted.
If the treating clinician is unable to
ascertain what the person would have
wanted
then they will need to make the decision
for the patient based on the patient's
best interests.
This legal framework focuses on
individual decision-making
and autonomy, it does not support
collective decision-making.
So in summary it is ideal if the
advance care plan is documented in the
national advance care plan template.
This increases the chances that what
matters most to a person and their
whānau
is used to direct their care now and in
the future.
In this advance care plan template a
person can communicate
what matters most to them and what
worries them, why they are doing an
advance care plan,
how they like to make decisions and who
they want to make decisions on their
behalf,
what they want when they are dying, what
they would like to happen if they cannot
communicate for themselves,
any advance directives including refusal
of life-sustaining treatments,
their wishes after death.
It's best if an advance care plan is
completed with the support of a
clinician
who also signs the document. The advance
care plan
can then be shared with whānau,
the enduring power of attorney
and the health care team. A copy should
also be available in the medical record
so it's easily accessible
and it can be reviewed when there has
been a change of circumstances.
An advance care plan does not need to
meet any of these criteria to be useful
but it will be easier to use if it does.
The process of creating this plan is a
benefit for individuals,
their whānau and their health care team.
It can help everyone navigate the legal
framework of care
when a person is unable to communicate
for themselves.