Advance care planning (ACP), sometimes referred to as anticipatory care planning, can encompass advance statements, treatment escalation plans and do not attempt resuscutation (DNAR) decisions.
It has always been difficult to determine the right time to initiate conversations of this nature, but COVID-19 has provided a fresh impetus, particularly in relation to those patients at higher risk.
NICE guidelines advise that when possible, discuss the risks, benefits and possible likely outcomes of treatment options with patients with COVID-19, and their families and carers, so they can express their preferences about their treatment and escalation plans.1 NICE has also recommended that clinicians should encourage patients with severe COPD to develop an advance care plan during the pandemic.2
Advance care planning also forms a key plank of the how practices are expected to help support care homes during the second phase of the NHS's response to the pandemic.
So how can GPs best approach these conversations and what are the key medicolegal issues?
Capacity and consent
GMC guidance states that you must work on the presumption that every adult patient has the capacity to make decisions about their care and treatment. Therefore, if the patient has capacity in relation to the matter in question, the discussion must be with the patient.
If the patient lacks capacity to make a particular decision, then you need to consider how best to proceed in the patient’s best interests; which may involve a discussion with their family or others close to them. This may present an opportunity to use technology through telephone or video conferencing to facilitate such discussions.
Regardless of the unique circumstances, we would recommend doctors make a record of the reasoning behind any decisions made, and the information given to patients, in case it is necessary to explain the approach taken later.
It is key that you have consent to proceed with a consultation. It can be an emotional discussion for the patient to have and it is important that this is acknowledged at the outset. The patient should also be reassured that at any point they can ask you to stop or go over something again.
If the patient feels overwhelmed it may be better to agree to revisit the matter at a later date rather than continuing or to suggest a family member/ carer joins the discussion
Communication and content
It can take time to build up a rapport between doctor and patient, and so it is helpful if the conversation on ACP can take place with a doctor who knows the patient well. If the patient is new to the GP surgery, this can be more difficult.
A further hurdle due to COVID-19 is that these conversations are now taking place over the phone, rather than face-to-face, and possibly after a letter may have been sent and has caused alarm.
The GMC provides advice on applying its ethical guidance to remote consultations. Even if you are not the patient’s usual doctor, you need to ensure you have a good knowledge of the patient’s medical background before a conversation. You also need to understand whether they have any preconceptions and it can therefore be useful to be aware of the patient’s cultural background and religion (if any).
A useful starting point can be to explore the patient’s understanding of their prognosis if they have a specific diagnosis, for example, end-stage COPD or end-stage heart failure. You may then ask whether they have thought about what they wish to happen if their condition gets worse, for example, as a consequence of COVID-19.
It is particularly important to avoid medical jargon in describing what may be involved; such as using terms like 'putting a tube down the throat', 'allowing a machine to take over your breathing' – rather than intubation and ventilation.
This can, if appropriate, lead on to a discussion around resuscitation and whether the patient wants resuscitation to be attempted or not. This is ultimately a clinical decision, but it is important to consult with the patient and make sure that their wishes are recorded.
Treatment escalation plans are a spectrum and if a patient does not wish to be resuscitated, many fear that they are not going to receive any treatment, so this needs to be addressed.
You can also draw on your local palliative care team where appropriate, who can provide guidance on anticipatory medication for symptom control, for example, in relation to pain or with respiratory symptoms such as breathlessness, which can be quite frightening.
Continuity of care and documentation
The GMC has stated that you must make a record of the discussion and of the decisions made; as well as making sure the ACP is made available to the patient, and is shared with others involved in their care.
You therefore need to make it clear that you are recording the information about what the patient wishes and who will have access to the information. It is also advisable to tell patients to keep a hard copy of the ACP at home and to ensure their carers know where this is kept.
Finally, patients and relatives should be given time to think things through and know that they can change their mind. If this happens, the ACP needs to be updated accordingly, and the discussion about the change in the patient’s wishes recorded in their medical notes.
If you have any concerns about handling ACP conversations, contact your medical defence organisation for support.
- Dr Bobby Nicholas is a medico-legal consultant at Medical Protection.