Objective To investigate the impact of advance care planning on end of life care in elderly patients.Design Prospective randomised controlled trial.Setting Single centre study in a university hospital in Melbourne, Australia.Participants 309 legally competent medical inpatients aged 80 or more and followed for six months or until death.Interventions Participants were randomised to receive usual care or usual care plus facilitated advance care planning. Advance care planning aimed to assist patients to reflect on their goals, values, and beliefs; to consider future medical treatment preferences; to appoint a surrogate; and to document their wishes.Main outcome measures The primary outcome was whether a patient’s end of life wishes were known and respected. Other outcomes included patient and family satisfaction with hospital stay and levels of stress, anxiety, and depression in relatives of patients who died.Results 154 of the 309 patients were randomised to advance care planning, 125 (81%) received advance care planning, and 108 (84%) expressed wishes or appointed a surrogate, or both. Of the 56 patients who died by six months, end of life wishes were much more likely to be known and followed in the intervention group (25/29, 86%) compared with the control group (8/27, 30%; P<0.001). In the intervention group, family members of patients who died had significantly less stress (intervention 5, control 15; P<0.001), anxiety (intervention 0, control 3; P=0.02), and depression (intervention 0, control 5; P=0.002) than those of the control patients. Patient and family satisfaction was higher in the intervention group.Conclusions Advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives.Trial registration Australian New Zealand clinical trials registry ACTRN12608000539336.

Background Advance care planning (ACP) assists patients to document their future medical treatment wishes and to appoint a surrogate. It is assumed that discussion with patients about their medical conditions, treatment and prognosis will influence and potentially change these decisions. Aim To assess the impact of ACP on decision-making regarding: (1) Patient wishes regarding cardiopulmonary resuscitation (CPR), and life-prolonging treatment (LPT); (2) Whether they have and correctly report having a surrogate. Methods In our previous study (BMJ 2010) of 154 patients allocated to ACP intervention, 125 completed ACP and108 expressed wishes regarding CPR and LPT. At study enrolment all patients were asked whether they already had any wishes on end-of-life care including CPR and LPT, and whether they already had a surrogate. Results LPT, and CPR (%) Decisions Yes Yes- DOO* No Delegate# Don't know CPR Pre-ACP 25 19 43 0 13 Post-ACP 4 30 49 17 0 LPT Pre-ACP 62 7 29 0 2 Post-ACP 3 36 36 23 2 *depending on outcome #delegating decision-making to surrogate/doctor. Nomination of surrogate After ACP 58 patients had a surrogate, 18 of which were pre-existing. At enrolment only 10 of these correctly identified they had a surrogate, 6 said they did not and 2 didn't know. Conclusion Following ACP many patients change their wishes regarding CPR, and LPT, often to less aggressive treatments and often choose to delegate decision making to others. ACP also assists patients to nominate and understand the important role of surrogates.

BackgroundMany patients with terminal illness and progressive loss of control over their bodies explore the option of euthanasia as a means to regain control. Some of these patients are referred by health professionals for advance care planning (ACP). This case study illustrates the difficulties involved.Case summaryMH had advanced Multi System Atrophy, a terminal disease involving progressive paralysis and pain and was being cared for at a nursing home. At the time of referral to the Respecting Patient Choices (RPC) Program, she was actively seeking advice from voluntary euthanasia organisations, and was exhibiting increasingly severe symptoms of depression as her disease progressed. The psychiatric liaison service viewed the initiation of involuntary treatment as inappropriate in this context. At this point a referral to the RPC program was made. ACP was conducted with MH, and she and her family completed an ACP including the appointment of a substitute decision maker, and the completion of a refusal of treatment certificate. MH was subsequently admitted to a specialist palliative care unit, where she died shortly after admission.DiscussionThis case touches on a number of issues around requests for hastened death, demonstrates a failure of terminal care provision and highlights the need for ACP at the time of diagnosis or early in the course of a terminal illness. Even at a late stage, ACP provided MH with information regarding her treatment options and allowed her to gain a sense of control over aspects of her treatment.Case summaryMH had been diagnosed with Multi System Atrophy, a terminal disease involving progressive paralysis and pain, 6 years prior to referral and was being cared for at a nursing home. At the time of referral to the RPC Program, Austin Health, Melbourne, she was suicidal, was actively seeking advice from voluntary euthanasia organisations, and had been assessed by the psychiatric liaison service as meeting the diagnostic criteria for major depression. The psychiatric consensus was against initiating involuntary treatment. At this point a referral to the RPC program was made. An ACP Clinician met with MH and her family to assist her to complete an advance care plan including the appointment of a substitute decision maker and the completion of a refusal of treatment certificate. She was also informed of her right to refuse further medical treatment. MH was subsequently referred, and admitted, to a specialist palliative care unit, where she died within 24 h of admission.DiscussionThis case demonstrates a failure of terminal care provision and highlights the need for ACP at the time of diagnosis. Even at a late stage ACP offered an alternative to euthanasia in a situation where she and her family felt that they had no other options.

BackgroundThe Respecting Patient Choices team has been doing advance care planning since 2002. We encourage people to nominate a substitute decision maker (SDM) and document their health care wishes on a ‘Statement of Choices’ (SOC). This document has evolved and now includes four components to ensure that the written plans are understood and appropriately acted upon by doctors.They are:to record a person's wishes about future medical treatment based on their goals, values and beliefs.to record this information in a language that doctors would recognise and could act upon.be easy to fill in.to provide prompts for people facilitating the ACP conversation.AimTo evaluate the evolution of the SOC.MethodsA retrospective audit of SOC completed in 2010.ResultsMost people (70%) choose to nominate a SDM and complete a SOC. People generally nominate a family member as their SDM and the majority (>90%) indicate on their SOC that they ‘would not want CPR even if the doctors think it could be beneficial’ and ‘do not want life prolonging treatment (LPT) at all’. 25% provided guidance on what would be an ‘acceptable outcome’. The SOC is recognised by the doctors and is acted upon.Conclusions▶Austin Health has devised a SOC form that enables people to record their medical treatment preferences especially in relation to CPR and LPT.▶The SOC is being further evolved for specific chronic conditions (eg, dialysis).