Overview of advance care planning and advance healthcare directives and guidance available when supporting people with dementia

1. Advance Care Planning &
Advance Healthcare
Directives
ICHN: New Horizons -
Enhancing Clinical Practice in
Community Nursing
May 2018
Deirdre Shanagher

2. Today:
• Advance Care Planning (ACP)
• Advance Healthcare Directives (AHD)
• Implications for community nursing
• Questions

6. Advance Care Planning –What is
it?
Voluntary discussions over time about future care
Process not task – may be more than one conversation
When we know things may change
When we know decision making in the
future may be difficult

7. Oct 30th 09 ST/AON
What might be included in ACP
discussions
Spiritual

8. What might be discussed (medical)?
• Use of preventive health screenings, medications and dietary
restrictions, invasive medical procedures and tests
• Hospitalisation
• Use of intensive care units and ventilators
• Artificial nutrition/hydration
• Use of antibiotics
• Cardiopulmonary resuscitation
• Making advance healthcare directive

9. Guidance for healthcare professionals:
• Always presume decision making capacity
• Help the person to maximise their decision making
capacity
• Remember that the person with dementia can choose
not to take part in the advance care planning process
• Be aware of how to assess a persons decision making
capacity if required to do so
• Gain knowledge on what steps to take if decision
making capacity is an issue
• Check existing advance care plans with the person
regularly for validity and applicability

10. If decision-making capacity is an issue:
1. Support the person to be involved in the decision-
making process by engaging in capacity building and
maximising.
2. Consider the level of support that the person
requires to make the decision in question.
3. Seek evidence of previously expressed
preferences.
4. Consider which option, including not to treat, would
be least restrictive of the person’s future choices.
5. Consider the views of anyone indicated by the
person. These people may be those appointed by
the person to support them when making decisions.
6. A Consider involving advocacy support.

12. Have you ever talked to
anyone about what you
would or wouldn’t want if
something unexpected
happened. Sometimes
people like to write things
down/make what’s called
an advance healthcare
directive
Is there
anything
that you’d
like to tell
us about
supporting
you in the
future?
Do you have any
worries or wishes
about your future
care/health care?
How do we start?
Have you
ever
heard of the
Think Ahead
Initiative?
Have you
ever heard
of an
advance
healthcare
directive
Have you ever
thought about what
you might want if you
became very
unwell…?

14. The Assisted Decision Making (Capacity)
Act 2015:
• Replaces the Lunacy Regulation (Ireland) Act 1871
• Includes provision for Advance Healthcare Directives which
were previously legal under common law but had no legislative
underpinning.
• Codes of Practice/Guidelines for full implementation required
• Minister for Justice responsible for commencing most of the
Act
• Minister for Health responsible for commencing the AHD
section

15. Where we are now.
Phased commencement
• Decision Support Service(DSS) is to be established
• Aine Flynn - Director and took up post in Oct 2017
• Codes of practice in development
• AHD multidisciplinary working group established (prepare
recommendations for code of practice for AHDs)
• Consultation closed May 4th 2018

16. Advance Healthcare Directives:
• A document where a person can write down what they
would not like to happen in relation to certain medical care
treatments
• Only comes into force when a person loses capacity,
becomes ill and the circumstances in their advance
healthcare directive arise. (A record of advance healthcare directives will
be held by the Director of Decision Support Services).

17. Issues that may be covered in an advance
healthcare directive:
• Treatments that a person would refuse in the future – this is legally
binding
• A request for a specific treatment. This is not legally binding but must be taken
into consideration during any decision-making process which relates to treatment for the
person in question if that specific treatment is relevant to the medical condition for which
the person may require treatment.

18. What makes an AHD legal?
• The person had decision making capacity at the time
they made the advance healthcare directive.
• The advance healthcare directive was made voluntarily.
• The advance healthcare directive was not altered or
revoked.
• The person who made the advance healthcare directive
did not do anything inconsistent with the terms of the
advance healthcare directive while they had decision
making capacity.

19. Think Ahead form
Includes an
advance care
directive
compliant with
the new
legislation

20. Think Ahead form
Think
Talk
Tell
Recor
d
Revie
Sections:
1. Key Information
2. Care Preferences (AHD
and emergency summary
form)
3. Legal
4. Financial
5. When I Die

21. Implications for community nursing:
• Be aware of assumptions re decision making
• Recognise and seize opportunities that arise
naturally in relation to ACP
• Share information with other MDT members
• Keep up to date in relation to legislation
• Be aware of the role of families (EPA, DHR)

23. Deirdre Shanagher
Deirdre.shanagher@hospicefoundation.ie