Contributor: Dr. Erin Gallagher
Summary:
When planning for the future, all decisions made by and for the patient should be guided by their values and preferences. Many tools exist to facilitate this aspect of care and conversations can be chipped away at over time. “Sprinkling in” these aspects of care is a different and more natural approach in primary care, in contrast to the concentrated way we often learn these skills on designated palliative care and hospital-based rotations in residency.
Advance Care Planning (ACP) is a continuous process, allowing others to know what kind of health and personal care a patient would (or would not) want in the future if they could not speak for themself. Patients will need to choose a Power of Attorney (POA) for personal care if they are not satisfied with their designated Substitute Decision Maker (SDM). Goals of care conversations incorporate any advance care planning you may have done into specific plans for your care and treatment. Questions that help facilitate these conversations include:
- What abilities are essential for you to feel you have a reasonable quality of life?
- When you think about the future, what do you worry about?
It can often be helpful to “hope for the best” alongside a patient (ex. wishing for a cure or longer prognosis) while preparing for alternative outcomes, as we know that tackling these challenging conversations upfront can help patients live better (and sometimes longer) to the end. Most people reach a time in their illness trajectory where they no longer want life-prolonging measures of any kind, including the treatment of simple complications such as infections. Reassurance can be provided in describing the variety of symptom-relief measures we have to actively support them until end of life.
Other important topics of discussion include the desired place of death, including a back-up plan, and funeral arrangements so the family is not burdened by this in their time of acute grief.
Discussions around resuscitation are often done poorly. When a clinician has a good sense of a patient’s values and wishes, medical knowledge can be applied to make a person-centred recommendation around this specific treatment. A DNR-C protects a patient from receiving a level of care they do not want; it does not prevent them from calling 911 or receiving active care otherwise up to that point. Another important document for completion is the Letter of Understanding, which allows the visiting nurse to pronounce the patient, giving the physician or nurse practitioner 24 hours to submit the death certificate (can be done electronically).
Take Away Tidbits:
The Palliative Approach in Family Medicine
- Identification (see May 2022 InfoMorsel)
- Illness Understanding (see August 2022 InfoMorsel)
- Whole-person Symptom Management (see December 2022 InfoMorsel)
- Planning for the Future
- Advance Care Planning (ACP) and Goals of Care (GoC) conversations
- Substitute Decision Maker (SDM) and Power of Attorney (POA)
- Place of death
- Funeral arrangements
- Important documents
Resources:
- Serious Illness Conversation Guide: http://www.bccancer.bc.ca/new-patients-site/Documents/SeriousIllnessConversationGuideCard.pdf
- Advance Care Planning: https://www.advancecareplanningontario.ca
- Communication Tools: https://www.vitaltalk.org/resources/
- Power of Attorney Kit: https://www.publications.gov.on.ca/300975
- DNR-C P Order Form: http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/MinistryDetail?OpenForm&ACT=RDR&TAB=PROFILE&ENV=WWE&NO=014-0350-93
- Letter of Understanding – Pronouncement and Certification of Death: https://healthcareathome.ca/document/hnhb-letter-of-understanding-for-pronouncement-of-death/
- Medical Certificate of Death: https://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=11291&NO=007-11291E (for a version that can be submitted electronically e-mailmcod.support@ontario.ca)