Abstract

What we mean by ‘advance directives’, in the United States has been largely determined by the creation of laws and regulations. The unintended consequence of this approach has been the creation of advance directives as one-time, singular events intended to be effective for all individuals regardless of age, stage of health, or changing goals and values. The literature in the USA has clearly demonstrated the failure of this legalistic approach.

Advance care planning (ACP) as a process of communication has emerged as an alternative to this failed approach. However, ACP is not a ‘one size fits all’ intervention. It is unrealistic and unhelpful to expect individuals to make healthcare decisions that will apply to all situations that may happen for some future point in time. Rather, ACP is more effective when it is focused on the individual's stage of health and the realistic decisions that may be needed for that stage. This staged approach to planning includes person-centred interactions and shared decision-making with professionals who are well trained in a standardized approach.

In this presentation the speaker will discuss the advantages of one approach to the stages of planning, described as First (ie, basic ACP for the healthy adult), Next (ie, disease-specific ACP for progressive chronic illness with complications), and Last Steps (ie, those expected to die in the next 12 months). This stage of planning approach makes it possible to identify the content of planning relevant for the person at each stage, when to do it, how to document it and how to train professionals to competently assist in the planning process. Quality improvement activities can be specifically designed to evaluate if the goals of planning are achieved.

This staged approach to planning is individualized and realistic. It builds care planning into the routines of care, enhances person-centred decision-making and provides a system for reviewing and updating plans over time. It is more likely an individual's goals and values will be known and respected.