(RELAXED MUSIC)
- Advance care planning is a process.
In New Zealand, advance care planning is a process.
The focus is on understanding what is important now and in the future.
The process of exploring your hopes, goals, worries and care preferences
by thinking, talking and sharing
what matters most to you and your whānau.
Understanding what the future might hold for you and your health,
what care and treatments are available — you know, your options.
Using that to support care and treatment planning
and decision-making.
We have a number of tools to support people, their whānau
and the members of their health care team during this process.
Firstly, an advance care plan.
This records the person's hopes, goals, worries
and treatment preferences and may also include advance directives.
You know, advance directives are a consent or refusal
to specific treatments
that may or may not be offered in the future when the person is unable
to communicate their consent or refusal.
The next tool is the serious illness conversation guide.
This is a guide to support health care staff
to talk about advance care planning with seriously ill people.
You can see it's a scaffolding or structure with conversation prompts.
It guides the clinician through setting up the conversation,
seeking permission, checking the person's understanding
of their health and what may be ahead, sharing a prognosis
and then exploring the person's priorities, worries
and what gets them through the tough times, their critical abilities
and what they're willing to go through for more time.
And then closing the conversation with a recommendation
and affirmation that the clinician will do everything he or she can
to ensure the person gets the best care possible.
The next tool is shared goals of care.
The shared goals of care principles and forms
support advance care planning during a hospital admission
or during the time a person is in an aged residential care facility.
Shared goals of care are when clinicians, patients,
families and whānau explore the patient's values,
the care and treatment options available
and agree the goal of care for the current admission
and if the patient deteriorates.
The shared goals of care principles provide guidance
to health care providers on developing
and supporting a shared goals of care approach
and outlines what is required for shared goals of care discussions
with adult patients, their families and whānau.
The shared goals of care form supports the discussion with prompts
and space to document the discussion on the one side;
on the flip side is where the shared goals of care plan is documented —
the goals that will inform the care and treatment decisions
should the person deteriorate.
There are a number of other tools
to support the advance care planning process,
including Te Waka Kakarauri ...
Whenua ki te Whenua, Te Ara Whakapiri and many others
that can be found on the advance care planning website —
www.myacp.org.nz.
Let's now look at how these come together.
The advance care plan and advance care planning
ideally starts early, before a serious illness.
It should then inform any subsequent
serious illness conversation guide conversation.
The information gathered
in the serious illness conversation guide-supported conversation
should be recorded and added to the advance care plan.
The serious illness conversation guide supports
shared goals of care discussions. The key points of that conversation
are recorded on a shared goals of care form
and inform the recommendation or goal of care
for the specific hospital or aged residential care admission.
The advance care plan and planning
should inform that shared goals of care conversation.
On discharge, the information and recommendations
might prompt a review of the advance care plan.
Let's now look at how this plays out over time.
Imagine advance care planning as a set of overlapping sound waves
that expand and contract over time.
The relevance and the level of advance care planning activity
for a person and their whānau expands and contracts over time,
triggered often by life events — like when you update your will
or when someone you love or care for becomes unwell,
or you might move house or need increasing support
with your daily activities,
or you start struggling with your short-term memory —
and health events — like, I don't know, a visit to the GP;
diagnosis of a chronic or life-limiting illness;
a health complication, like a fall. And in between times,
a person and their family might spend no or little time
thinking or talking about advance care planning.
And as it expands and contracts,
the person will use their advance care plan to support their thinking,
talking, planning and sharing.
Let's now look at this from the perspective of interactions
with the health care system, when what matters most
to the person and their whānau — their preferences — are discussed
and used to plan ahead and to inform care and treatment.
These can be times where advance care planning can be supported —
for example, when talking about support in the community
or, generally, with a GP;
maybe when the person lands up in hospital
or as their health deteriorates;
if they potentially lose capacity,
and particularly in those last weeks, days, and as they die.
These are all opportunities for advance care planning,
using what matters most to the person to inform their care.
Now let's look at how various tools that support advance care planning
might be used.
The advance care plan is relevant and should be added to,
used and reviewed throughout the process.
It should inform discussions with the GP, on admission,
during admission, whilst receiving care in the community
or in aged residential care.
So, for example, during a GP visit,
the GP or practice nurse might refer to it.
Or if the person has become seriously ill, they might use
the serious illness conversation guide to support that conversation.
On admission to hospital or an aged residential care facility,
the health care team will want to determine the direction of care
and agree shared goals of care, should the person deteriorate.
This should start with reference to any advance care plans
and documented conversations.
The clinician might use the serious illness conversation guide
to help structure the conversation
and should then capture any shared goals of care or treatment decisions
that result. And on discharge,
any new information should be shared with the GP to prompt
an advance care planning review and care plan in the community.
If the person loses capacity, the advance care plan
and any documented conversations or discussions should inform
the treatment and care planning and provision.
And as a person is dying,
we should honour the person and their whānau's wishes
by using the information we know about the person's preferences —
what matters most to them —
to provide care and treatment that best matches that.
So, to wrap up — advance care planning is a process of discussion
and shared planning for future health care.
It involves an individual, their whānau and health care professionals.
Advance care planning gives people the opportunity to develop
and express their preferences for future care based on their values,
beliefs, concerns, hopes and goals,
a better understanding of their current and likely future health
and the treatment and care options available.
It is our responsibility to ensure that each and every one of us
supports the process and uses the information
that people share with us.
Ma tini, ma mano,
ka rapa te whai;
by many, by thousands, the work will be accomplished.
Unity is strength.
Ngā mihi.
(RELAXED MUSIC)