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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Site Index
    Back to Module 1: Advance Care Planning
    Introduction to Advance Care Planning

    What is Advance Care Planning?
    Advance Care Planning Terminology
    Objectives of This Module

    What Is Advance Care Planning?

    • Process of planning for future medical care
      • Process, not a discrete event
        • reviewed with patient and staff
        • updated regularly with each review

      • Ensures patient's wishes will be respected in the event that the patient is unable to make his or her own decisions
    • Exploration and documentation of values, goals during which patients...
      • Identify and clarify their personal values

      • Express goals about health and medical treatment

      • Identify the care they would like, or not like, to receive in various situations
    • Determination of proxy decision-maker
      • Makes health care decisions on patient's behalf in the event they cannot make decisions for themselves
    • Professional and legal issues in advance care planning
      • Patients have right to participate in the planning of their health care

      • Physicians have a legal and professional responsibility to assure this, even if the patient loses the capacity to make decisions
    • Successful advance care planning depends on your ability to structure discussions with the patient that:
      • Convey the information patients need

      • Elicit relevant preferences to determine their advance directives

    • A script is provided at the end of this module in the Resources that you may wish to use or modify. It may help you to think about ways to conduct the discussion


    Advance Care Planning Terminology

     Advance Directives

    • Prior directives by the patient for his or her health care
    • Fall into two categories:
      1) those that have to do with instructions for medical care
      2) those that have to do with designating a proxy for the patient

    Instructional Directives for care can be recorded in a number of types of documents:

    • A living will is usually a simple statement asking for no heroic care in case of poor prognosis.  A personal letter may also be used
    • A values history is a statement of values regarding health care in life-threatening illness situations
    • A medical directive is a set of instructions based on likely scenarios of illness, goals for care, and specific treatments, combined with a general values statement. It is also combined with a proxy designation section
    Health Care Proxy
    • A person who is empowered to make decisions in the place of the patient
    • Also known as a durable power-of-attorney for health care

    Laws and policies regarding advance care planning are summarized in the Resources section of this module and are presented in more detail in Module 15: Legal Issues in End of Life Care


    Objectives of This Module

    • Define advance care planning and explain its importance
    • Describe the steps of the advance care planning process
    • Describe the role of patient, proxy, physician, and others
    • Distinguish between statutory and advisory documents
    • Identify pitfalls and limitations in advance care planning
    • Be able to utilize planning to help put patient affairs in order
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