clinical focus
So the idea is, since doctors and nurses
become familiar with these prognostic
tools, they’ll be a bit more confident
about the certainty of the prognosis and
the fact that there is an impending death
in front of them, and that it’s time for that
honest conversation.
Of course, their training is how to
formalise an advance care directive. So
there are multiple tools on the internet
and from the NSW Health Department
where there are indications on how
to conduct the conversation, how to
document it and what to do with those
documents afterwards.
How can staff approach these
conversations with family?
It is more commonly happening in the
intensive care units, because families, I
suppose, expect that there could be a
death, because intensive care means the
patient is critically ill. In those cases, there
is a family conference, usually led by a
doctor, but it also includes the allied health
personnel and nurses treating the patients.
And that is done in a very sensitive way by
those experienced people.
The main reason these aggressive
treatments are happening outside the
intensive care unit is basically because
there is little training during the medical
and nursing courses about breaking
bad news when a person is facing
impending death.
So, the approach could start by asking
the family if they know the patient’s
wishes or their preferences or their values,
whether they value quality over quantity
of life. And they can also ask the patient
if they’re aware of the seriousness of the
illness and how they think they’re travelling
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and whether they think the treatment is
being beneficial to them or not.
In general, what we recommend is that
those conversations start even before
the person gets to hospital – with the GP
or with their relatives. That’s talking over
dinner about when somebody is very ill
and of advanced age, what do they want
to go through? What do they not want
to go through? And I guess, mostly, it’s
the partners of those patients who know
exactly what they want, but in some
cases and in some cultures, that topic is
still taboo.
We still recommend discussing it, even
if it’s just a little bit. Even if it’s just one
single conversation. This will all help
the doctors and nurses make decisions
when the person comes to the hospital
in a crisis.
What roles do nurses in aged care
facilities play in supporting people
with writing an advance care directive?
I think the nurses have a very important
role to play. The main thing they can do
is obviously use the prognostic tools to
have their own certainty of prognosis with
the patient, but particularly in residential
aged care facilities, there is more time
than there is in an emergency situation. So
nurses in aged care facilities can assess the
patient with the checklist and can have the
conversations.
We have noted that nurses have more
ability to have those conversations
and more time than the doctors in
emergency, so we recommend that they
make the patient familiar with what an
advance care directive looks like: maybe
provide them with a printed copy of a
sample or a blank template and guide
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them through it, or leave them alone to
discuss it with their families and then
come back to it.
Obviously, those decisions are not set
in cement, so the advance care directive
conversations can be had several times
over the course of a particular illness.
Some patients can change their mind
about the treatment as the disease
progresses.
We also notice that families sometimes
go in one direction and the patient goes
in another. But it’s the patient who is
suffering the chronic illness and the
intensive treatment, and they may say
enough is enough. Whereas families may
say, we don’t want to let go.
So this is the sort of discussion that
needs to be held, not just with the patient
but also with the family, so there is an
agreed, shared decision.
Is there anything else you’d like to add?
The main message of this paper is that we
need to draw the line on administering
these aggressive treatments if the risks
outweigh the benefits and if the outcome
is predictably poor.
So, if we know that the person is
80 years of age, has an advanced chronic
illness, or two or more, has had previous
hospital admissions in the past few
months, is on more than six medications,
and is not an elective admission but
arrived at the emergency department,
and in particular, if they have a ‘no
resuscitation’ order – all of these are flags
that should warn the doctor or nurse that
this person is eligible for an end-of-life
conversation, so that those treatments
that are aggressive, costly and painful can
be prevented. ■
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