The Advance Care Directives Act is an important step forward for all of us, that work in health in South Australia.
The most obvious bit that you'll see is that
the existing Medical Power of Attorney, Anticipatory Direction and Enduring Power of Guardianship
has been simplified into a single Advance Care Directive Form.
The new form will allow individuals to appoint family, friends or caregivers as substitute
decision makers to make decisions for a time in the future, if they're unable.
But the more important bit is improved law for when we have to treat patients who have
lost the capacity to make decisions, such as when they are unconscious, mentally ill
or near the end of life. The act promotes the self-determination of
people receiving healthcare, and, as a central principle, it asks everyone; substitute decision
makers, family and doctors, to make decisions on behalf of the person, as they would have done.
But it is also good law for all of us that
work in health because it supports and protects good care and the way we should be working
with our patients. Hopefully, as we become more familiar with
new the Act, and also the 7 Step Pathway Resuscitation Plan, we'll be able to make better decisions
about resuscitation and end of life care. You'll see that we'll all be able to work
with greater certainty and confidence in respecting the wishes of the patients that we look after.
And to work in partnership with us, our families and our caregivers as we need you to.
Good Morning, how can I help you? Hi. I'm Michael Novac and this is my daughter,
Sophie. I've been sent here from Outpatients to be admitted.
Michael... Yes, I see, Dr Lim phoned to let us know you were coming down. You've been
an inpatient before? Yes, unfortunately, I have been one of your
more frequent patients lately.
I'm sorry to hear that, I'll just check to make sure all of your details are up to date.
Now that all your other details are up to date.
Do you have an Advance Care Directive? Ah, yes, I always carry it with my medication form.
That's really helpful.
The doctors will need a copy in your medical record, and I can arrange to have a certified copy made so you can keep the original.
Thank you.
Have you appointed a Substitute-Decision Maker in your Advanced Care Directive?
Ah yes, my daughter Sophie here. Her details are right there on the ACD form there,
you can copy them from the form if you like.
Is Sophie also your Emergency Contact? No, my son James is the best contact in case
of an emergency. I had off work today to bring dad in but,
I'm a teacher so quite often I don't have access to my phone during the day, but my
brother James he's easier to get in contact with. I'll just give you his number.
Oh, four, two, three, triple five, five, seven, two.
Okay, emergency contact: James Novac, oh, four, two, three, triple five, five, seven, two.
Yep, that's correct.
That's all I need, the orderly will be down shortly to take you up to the ward. You may
take a seat back in the waiting area. Thanks. Thank you.
Hi Kimberly.
Hi Dr Lim. Good timing, I was just about to page you. Now look, I've just done a set of
admission obs on Mr Novac. And I've noticed that his resp rate is triggering an MDT review.
He's sitting around thrity, he seems really hypoxic, he's really agitated and really confused,
so I put him on some oxygen, is he usually like this?
He's not normally confused. Well I've put him on two litres of oxygen,
I've also noticed that he's febrile, thirty-eight two, and his pulse is a little bit up of 90. Look,
I think you really need to come and see him. The other thing too is, he has an advanced
care directive, which is in his notes, and he has a daughter by the name of Sophie who
I'm not sure if you've met already, but she's just stepped out to do a few things.
Yeah, let's have a look.
Hi Michael, how are you going?
What's this thing up, I don't like it, what's it for?
Michael that's just your oxygen, you need that one for your infection.
You seem a little restless, just let me have a listen to your chest.
Yeah, it's concerning isn't it, he's deteriorated quite a lot since I last saw him, but I think it's really important
to know what treatment he would've wanted should he get worse, but at the moment I think
he's a bit to delirious to make his own decisions. Do you mind keeping an eye on him, let me
know if his resp rate gets worse or is more agitated, I'm going to have a look at his
Advanced Care Directive and probably give Sophie a call.
Sure I can do that, that's fine.
So I just spoke to Sophie, and she was actually
quite upset to hear that he detiriorated so quickly. Okay. But in any case, we had a chat
about his treatment options, and although she wanted Michael to be for full resus,
we had a look at his Advanced Care Directive, which says he doesn't want to suffer, and
so if we put ourselves in his shoes she could see that his wishes would probably be more
conservative than hers, and so at this stage the plan is for antibiotics, salbutamol and prednisolone,
but he's not for CPR, he's not for ICU, he's not for insubation, and not for MER calls either.
Sure, now before you go, can you also make
sure that you do some modifications on his RDR chart for me.
Yeah, I'll do that and I'll make sure I write up some meds to make sure he's comfortable.
Thanks Doctor Lim, that sounds like a really clear plan, now look if we need any clarity
on what action to take, I'll make sure we give you a call. We want to make sure that
Mr Novac is as comfortable as possible. So let's just have a chat to him okay.
Hi Michael, how are you going? Michael I had a chat to Sophie, and she's going to be in soon.
We're just going to make sure that the Resus plan fits with the RDR chart.
So could you just check that the troponin is at nine o'clock?
Sure.
Um, the next patient for you to be aware of is Michael Novac. He's a sixty-five year old man.
Q8, bed 12. UR number is 213-213. Oh yeah, Mr Novac always in.
Yeah, unfortunately he's in again for ineffective exacerbation of COPD. Um, and you might get
called to see him because he's not for MER calls. I admitted him today from OPD, you
might know he's had a six month history of recurrent exacerbations and admissions, but
unfortunately he's deteriorated today quite rapidly. A chest x-ray has shown that he's
got a right lower lobe pnemonia. When I saw him, his resp rate was up and ABG showed a
P02 of 55 on 2 litres, and he was quite confused as well. Given that he was so confused, and
he might deteriorate further, I've had a chat to his daughter Sophie, who is his substitute
decision maker, um although initially she wanted him to be for full resus, we had a
look at his Advanced Care Directive, which says he doesn't want to suffer, and therefore
he's not for CPR, he's not for intubation, and he's not for ICU admission either, and
like I said, he's not for MER calls.
Is that documented in the resus plan?
Yep, um, now if he's to continue antibiotics at this stage, but if he deteriorates further,
he might just be for comfort measures.
Okay,so would you recommend I charter for some PRN morphene, clonazepam and hyoscine?
Um, yep that sounds good, and that's all documented
in his resus plan as well. His daughter Sophie should be informed of any changes.
Okay, good. Sounds like a clear plan.
Hi Michael, Hi Sophie, how are you?
Oh good, I think I'm ready to go.
That's wonderful news, I'm so glad that you've
made such a good recovery. Now, do you have your discharge medications that I gave you?
Just reminding you, with your discharge medications that you must take your full script of your
antibiotics and also do you have enough inhalers?
Yes I have enough for the next three weeks.
That's wonderful, now before I forget, here is a copy of your resuscitation plan, now
I would advise you that you keep that together with your advanced care directive and your
list of medications, which you'll find in your discharge medication bag.
It was a really good thing that you had your Advanced Care Directive when you came in, and Sophie as
a contact so that we could plan your care when you got so sick.
I'm not sure if Doctor Lim has told you, but you have an appointment with your GP next Friday, and I've also got
a copy of your outpatient appointment card. I'll make sure that Doctor Lim hands everything
over to your GP, including your resuscitation plan and your discharge summary.
Do you have any questions before I leave Michael?
No, I'm just happy with the plan,
I'm just glad I'm feeling a lot better and I'd like to thank everyone involved.
And Sophie do you have any questions?
No, I just wanted to say thank you as well, thanks to everybody for
working with me to sort out what Dad needed and it was especially helpful when you guys
said, you know 'to act as if I was walking in Dads shoes', that was helpful to help me
figure out what he would want.
Thank you so much for that feedback, and I hope Michael
we don't see you back here too soon.
Me too.
Take care.
Oh, hi, is that Doctor Moy?
Yeah, are you the GP for Michael Novac? Yeah, so he's just been admitted to the Royal Adelaide Hospital
for an ineffective exacerbation of COPD, um and I just wanted to hand over some details
about his admission.
Okay, yeah so he was admitted just a couple of days ago...
Doctor Thomas, um I've just been seeing a patient in the ED, they're a readmit under
your bed card, um do you have a moment to discuss it with me?
Sure.
Look, it's a Mrs. Mary Turner, she's a 83
year old woman, she's from home, um, she came in last month with a non stemi myocardial infarction,
and she was the lady that was on long term steroids and we couldn't work out why.
Yeah, I remember her well, how is she today?
Well, not doing so well. She's come in with a community acquired pneumonia, um, and she's
hypoxic and septic, and I'm really worried about her.
What's her mental state like?
She's disoriented, um and she's drowsy.
She's delirious, delirious from the pnumonia.
Okay, what do you think about her prognosis John?
I think she could deteriorate, I think she's
at a high risk of that, um, her son Hugh was there, and I noticed that she had, um an enduring
power of guardianship form in her folder, but also one of these new Advanced Care Directives.
The new Advanced Care Directive will supersede her previous paperwork, the enduring power of guardianship,
it's new legislation, there's some key differences in the new legislation,
um it's actually quite interesting, it will help ensure that everyone can comply with
the patients wishes, it helps us do what the patient would've wanted.
There's also greater protection for us if Mary's made any statements and we know what she would want done, we can
stand by that and it gives us good protection, particularly in emergency situations.
It's also nice because we're not really required to provide any treatement that wouldn't be
of benefit to the patient, so it's in line with the code of conduct for medical practitioners.
There's also some provisions for dispute if there is a dispute with any of the people
involved in making decisions, we can use the office of the public advocate to help resolve that.
Do you think she's got capacity?
No, she doesn't have decision making capacity,
she's grossly disoriented, and delerious.
Right, well that means that the Advanced Care Directive
comes into effect now, because she has not got capacity.
Well I read the form, um and, it appoints two substitute decision makers on the Advanced
Care Directive. So for medical decision makers, it mentions her son Hugh Turner, um and there's
Jan Turner for housing decision making.
Okay, are there any other directions in there?
Yeah, so um she specifically said here that she doesn't want to be resuscitated, she doesn't
want intubation, ventilation or CPR.
Okay so we're going to have to consult Hugh about
her treatment, um he'll have to take into account her expressed wishes there, and some
of the important things she's stated about CPR and ventilation. The important thing is
that we get Hugh to understand, if he doesn't already, that he really has to walk in her
shoes to help make decisions on her behalf.
Okay, well Hugh's here now, um and I was hoping
that maybe we'd be able to discuss a resuscitation plan. Would you be available for that?
Yeah, I'd be happy to do that.
Okay John, how do you think that discussion went?
Well I think Hugh um, understood his mum's wishes,
um and I think he understands the plan that we've made for his mum's care.
He seemed pretty upset though.
Yeah, I think that's understandable, he understands exactly
how unwell his mother is and, but I agree, we're all on the same page in terms of her treatment.
We really now have to translate that into a resuscitation plan.
Have you filled out one of these forms before?
Look, I actually haven't yet, um would you be able to go through it with me?
Yeah, I'd be happy to.
Okay, so we had a trigger which was that, Mrs Turner
was clinically deteriorating, and we'd assessed that she had a pnumonia with respiratory failure.
We've seen that she has a new Advanced Care Directive, um and we've also discussed it
with her substitute decision maker, her son Hugh, and so we discussed the fact that she
would be for antibiotics, um, but not for intubation or ventilation.
Yep, so that's the consultation part taken care of.
Yeah, I was a little bit confused by the discussion about the medical emergency response calls though.
Well, we discussed with Hugh about the MER call.
In light of the fact that she's not for ventilation, and not for CPR, escalating
her therapy in the event of a deterioration would be unlikely to be of any benefit to Mrs. Turner.
Hugh really understood that very clearly, and I think he has a great wish,
as do I, to prevent her from having unnecessary invasive treatments, you know lots of needles
and extra IV fluids at an MER call. I think what's important is that we have a plan to
keep her comfortable if that deterioration does eventuate, and so as we talk to Hugh,
about we should be writing up sedation, and analgesia appropriate for Mary if that's needed.
Sure, but she wanted antibiotics though?
Yeah, and that was definitely agreed, and
I'm happy to go with that as his role as a substitute decision maker, that was definitely appropriate.
So if you're happy to chart up the antibiotics, that would be good.
So I'll finish filling out the resuscitation form, and then I'll modify the RDR chart, um,
then I might just make sure the nursing staff are aware of the resuscitation plan, um, and then
I might just go see Mrs. Turner and Hugh again and make sure that they're still comfortable.
I think that's a great idea. They might have some more questions, it's been a fairly hectic day,
and you just want to make sure that they're fully comfortable with what we've planned
and that they're aren't any more things that they need to discuss at this stage.