ACP

Question 1

What is ACP?

Answer 1

A process of discussion regarding decisions on future health and personal care in the contexts of individual’s values and beliefs

Question 2

Why ACP?

Answer 2

• Identify and clarify own personal values and goals about future health and personal care
• DETERMINE SUBSTITUTE DECISION MAKER
• Build trust
• Reduce uncertainty
• Avoids conflict and confusion
• Enhance peace of mind
• Exercise autonomy

Question 3

Who is ACP for?

Answer 3

Everybody, regardless of age or health status

Note: It is NOT compulsory, and NOT a legal document

Question 4

What are the 3 approaches of ACP discussion?

Answer 4

1. General ACP
2. Disease Specific ACP
3. Preferred Plan of Care ACP

Question 5

Purpose of General ACP and who is it for?

Answer 5

Purpose: Identify nominated healthcare spokesperson and consider goals of treatment should a serious neurological injury occur

For: Early onset and medically stable patients

Question 6

Purpose of Disease Specific ACP and who is it for?

Answer 6

Purpose: Determine the goals of treatment as the complication escalates

For: Patients with progressive life-limiting illness and frequent complications

Question 7

Purpose of Preferred Plan of Care ACP and who is it for?

Answer 7

Purpose: Establish a specific plan of care when patient deteriorates

For: Patients with <12 months prognosis and/or requiring long term institutional care

Question 8

Requirements for ACP discussions:

Answer 8

• Patient has adequate mental capacity for discussions and has no mood disorders.
• Patient’s comfort is optimised.
• Patient’s sensory impairment is optimized.
• ACP facilitator has good communication skills and exhibits sensitivity (verbal and non-verbal).
• Optimal time allocation.

Question 9

Why is assessing the patient’s decision making capacity important?

Answer 9

Adults with decision-making capacity always make their own decisions, not their documents

ACP doc is valid only if completed by an adult who has the decision-making capacity.

ACP doc becomes relevant only if patients are determined to have lost the ability to make their own decisions.

Question 10

What are the barriers of initiating ACP?

Answer 10

Patient factors
Clinician factors
System factors

Question 11

(ACP barriers) If a patient is in denial of diagnosis or unclear, what do we do?

Answer 11

Discuss goals of care.

Question 12

(ACP barriers) If a patient is inclined to protect their family, what do we do?

Answer 12

Include family members in the care discussion.

Question 13

(ACP barriers) If the patient has low health literacy, what do we do?

Answer 13

Avoid jargons, use simple medical information, integrated explanation with pictorials or diagrams.

Question 14

(ACP barriers) If a patient wants to avoid the topic of death, what do we do?

Answer 14

Create more ACP awareness in the community.

Question 15

(ACP barriers) If the clinician does not have enough time, what do we do?

Answer 15

Time management.

Question 16

(ACP barriers) If there is lack of continuity during care transition, what do we do?

Answer 16

Integrate and enhance continuity of care and communication among stakeholders.

Question 17

(ACP barriers) If the clinician has lack of knowledge and confidence, what to do?

Answer 17

ACP facilitator training.

Question 18

(ACP barriers) If there is unclear prognosis of the patient, what do we do?

Answer 18

Goals of care discussion.

Question 19

(ACP barriers) If the clinician is focused on curing of the disease, what do we do?

Answer 19

Mindset change - focus on quality of life.

Question 20

(ACP barriers) If the focus is on life sustaining care, what do we do?

Answer 20

Focus on quality of life in the care goal discussion.

Question 21

(ACP barriers) What should the medical team agree on when discussing the patient’s ACP?

Answer 21

Advocate for achieving the patient’s goals.