Academic journal article Australian Health Review

Health Advance Directives, Policy and Clinical Practice: A Perspective on the Synergy of an Effective Advance Care Planning Framework

Academic journal article Australian Health Review

Health Advance Directives, Policy and Clinical Practice: A Perspective on the Synergy of an Effective Advance Care Planning Framework

Article excerpt

Australians are entitled to plan in advance the medical treatments they would allow in the event of incapacity using advance directives (ADs). A critical role of ADs is protecting people from unwanted inappropriate cardiopulmonary resuscitation (CPR) at the end stage of life. Generally, ADs are enacted in the context of medical evaluation. However, first responders to a potential cardiac arrest are often non-medical, and in the absence of medical instruction, default CPR applies. That is, unless there is a clear AD CPR refusal on hand and policy supports compliance. Such policy occurs in jurisdictions where statute ADs qualifying or actioning scope is prescriptive enough for organisations to expect all health professionals to appropriately observe them. ADs under common law or similar in nature statute ADs are open to broader clinical translation because the operational criteria are set by the patient. According policy examples require initial medical evaluation to determine their application. Advance care planning (ACP) programs can help bring AD legislation to effect (J. Cashmore, speech at the launch of the Respecting Patient Choices Program at The Queen Elizabeth Hospital, Adelaide, SA, 2004). However, the efficacy of AD CPR refusal depends on the synergy of prevailing AD legislation and ensuing policy. When delivery fails, then democraticADlaw is bypassed by paradigms such as the Physician Orders for Life-Sustaining Treatment (POLST) community form, as flagged in Australian Resuscitation Council guidelines.2

Amidst Australian AD review and statute reform this paper offers a perspective on the attributes of a working AD model, drawing on the Respecting Patient Choices Program (RPCP) experience at The Queen Elizabeth Hospital (TQEH) under SA law. The SA Consent to Medical Treatment and Palliative Care Act 1995 and its 'Anticipatory Direction' has been foundational to policy enabling non-medical first responders to honourADs when the patient is at the end stage of life with no real prospect of recovery.3 The 'Anticipatory Direction' provision stands also to direct appointed surrogate decision-makers. It attunes with health discipline ethics codes; does not require a pre-existing medical condition and can be completed independently in the community. Conceivably, the model offers a nationalADoption, able to deliverADCPR refusals, as an adjunct to existing common law and statute provisions.

This paper only represents the views of the author and it does not constitute legal advice.

Whatisknownabout the topic? Differences in advance directive (AD) frameworks across Australian states and territories and between legislated and common law can be confusing.4 Therefore, health professionals need policy clarifying their expected response. Although it is assumed that ADs, including CPR refusals at the end of life will be respected, unless statute legislation is conducive to policy authorising that non-medical first responders to an emergency can observe clear AD CPR refusals, the provision may be ineffectual. Inappropriate, unwanted CPR can render a person indefinitely in a condition they may have previously deemed intolerable. Such intervention also causes distress to staff and families and ties up resources in high demand settings.

Whatdoes this paper add? That effectualADlaw needs to not only enshrine the rights of individuals but that the provision also needs to be deliverable. To be deliverable, statuteADformulation or operational criteria need to be appropriately scoped so that organisations, through policy, are prepared to legally support nurses and ambulance officers in making a medically unsupervised decision to observe clearCPRrefusals. This is a critical provision, givenADsincommonlaw (or similar statute) can apply broadly and, in policy examples, require medical authorisation to enact in order to ensure the person's operational terms are clinically indicated. Moreover, compliance from health professionals (by act or omission) with in-situ ADs in an unavoidable emergency cannot be assumed unless the scope harmonises with ethics codes. …

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