Advance care planning

Last updated

Advance care planning is a process that enables individuals with decisional mental capacity to make plans about their future health care. [1] Advance care plans provide direction to healthcare professionals when a person is not in a position to make and/or communicate their own healthcare choices. Advance care planning is applicable to adults at all stages of life. [2]

Contents

Participation in advance care planning has been shown to reduce stress and anxiety for patients and their families, and lead to improvements in end of life care. [3] Older adults are more directly concerned as they may experience a situation where advance care planning can be useful. However, only a small portion of elderly use them. [4] [5]

The main components of advance care planning include the nomination of a substitute decision maker, and the completion of an advance care directive.

Definition

Advance care planning was defined by an international white paper as involving individuals with decisional mental capacity at the outset, being able to be fully involved in plans and discussions about their health care. [1] This has led to some countries in the United Kingdom using 'Future Care Planning' [6] [7] as an umbrella term, to include both advance care planning for those with capacity, and a planning for those with diminished or absent mental capacity (Best Interests decision making as defined by the UK Mental Capacity Act). Professor Mark Taubert, a palliative care consultant who is lead for Advance & Future Care Planning in Wales, published a position paper on this in 2022, [8] and NHS Scotland has also adopted Future Care Planning as an umbrella term, under which Advance Care Planning or Anticipatory Care planning are only a part-component.

Background

Advance care planning may have relevance for adults at any stage of life. [2] Advance care planning typically involves a conversation between people, their families and carers and those looking after them about their future wishes and priorities for care. [9] However, notions of advance care planning vary internationally. [10] Advance care planning aims to allow people to live well, and when death approaches, die in accordance with their personal values. [11] Advance care planning is only applicable when the individual cannot make and/or communicate decisions about what they want in relation to their healthcare. [12] If advance care planning has occurred, patients who have lost capacity or the ability to communicate or both, are able to continue to have a say in their medical care. [13] This has been shown to improve end of life care, and provide improved outcomes for both patients and their surviving relatives. [3]

While applicable to all stages of life, it is particularly applicable to perioperative planning and end-of-life care decision making, since approximately 1 in 4 people lose decision making capacity when approaching the end of their life. [14] [15] Results of a systematic review indicate there are several prognostic indicators to help identify patients who may benefit from advance care planning discussions while still in the primary care setting. [16]

Although ACP is potentially appropriate for nearly all adult patients, given the realities of a busy practice, it would be useful to have a system for identifying patients with a more limited prognosis.

Federal and state legislation in the US, [17] Australia, [18] Canada [19] and the UK [20] supports the right of patients to refuse unwanted medical treatments. People can also express their preferences through written advance directives or by advising their appointed substitute decision maker about their wishes for when they are unable to make or communicate these decisions/wishes themselves.

Increasingly digital approaches are emerging to support the documentation and sharing of advance care planning information, with the majority of approaches using electronic health record systems. [21] Whilst different approaches are emerging, there has been low uptake of digital advance care planning in countries including the UK. [22] Reasons for low uptake have been associated with implementation challenges experienced by health professionals, including interoperability challenges. [23] There is increasing recognition of the need for patients to have access to their own digital advance care plan to verify information stored about their care preferences. [24]

Components

There are two methods by which the communication of an individual's preferences can be known. These are:

  1. the appointment of a substitute decision maker, and
  2. the completion of an advance care directive or similar document.

Findings from a systematic review suggest the value and importance that various types of decision aids have for patients to use and help clarify their goals. [14]

Substitute decision maker

A substitute decision maker makes decisions on behalf of an individual only when that individual does not have the capacity to make/communicate decisions for themselves. [25]

There are a number of methods by which a substitute decision maker can be identified. The ideal method is the appointment of a person using a statutory document. In the absence of a statutory document the substitute decision maker may be a "person responsible" as listed in order of authority in legislation. [25]

A substitute decision maker can be chosen by an individual following completion of relevant paperwork, can be assigned to the person by law in the absence of a chosen substitute decision maker (e.g. family member or carer), or can be appointed for the person (e.g. guardian appointed by a guardianship tribunal). [26]

Substitute decision makers make decisions based on the principles of either substituted judgement or best interests. [2] Substituted judgement is when the substitute decision maker arrives at a decision based on the best approximation of what they believe the person would want. This decision should be informed by both the known wishes of the person and the best available healthcare advice. [27] Best interests decision making requires the substitute decision maker to focus on the patient's best interests.

Many, but not all, jurisdictions have legislation supporting the appointment of a substitute decision maker through a statutory document. They have different names depending on the jurisdiction:

JurisdictionSubstitute Decision Maker Type
AustraliaAustralian Capital TerritoryEnduring Power of Attorney [28]
New South WalesEnduring Guardian [29]
Northern TerritoryN/A
QueenslandEnduring Power of Attorney [30]
South AustraliaMedical Power of Attorney [31]
TasmaniaEnduring Guardian [32]
VictoriaMedical Treatment Decision Maker [33]
Western AustraliaEnduring Power of Guardianship [34]
United KingdomLasting power of attorney - health and welfare [35]
United States Health care proxy
CanadaNewfoundland and LabradorSubstitute decision maker [36]
Nova ScotiaDelegate Decision maker [37]
New BrunswickPower of Attorney for personal care [38]
Prince Edward IslandHealth Care Proxy [39]
QuebecMandatary [40]
OntarioPower of Attorney for Personal Care [41]
ManitobaHealth Care Proxy [42]
SaskatchewanHealth Care Proxy [43]
AlbertaHealthcare Agent [44]
British ColumbiaTemporary Substitute Decision Maker [45]
Yukon TerritoryHealth Care Proxy [46]
Northwest TerritoriesHealth Care Agent [47]
NunavutN/A

Advance care directives

An advance care directive is a document detailing an individual's health care preferences. This may include personal values and life goals, describe circumstances the person would find unacceptable, identify preferences relating to specific medical interventions, or a combination of these. [2]

Advance care directives may be written on specifically designed forms, but can also take the form of a written letter or statement. [48] Inclusion of a doctor in the completion of an advance care directive will assist in ensuring that an individual's wishes are clear and written in a manner that is easy for substitute decision makers and/or medical staff to interpret and follow them in the future. Having a physician witness the document will reinforce this by showing future medical staff that the document contains information about informed decisions due to the assistance of a physician. [49]

Advance Decisions to Refuse Treatment (United Kingdom)

Some countries do not use the term 'directive', due to advance statements and/or advance care plans not usually having the legal standing to enforce a directive (for instance, a patient cannot direct a doctor to give him a specific treatment at a later time-point i.e. when she/he loses decisional capacity). In the United Kingdom, Advance Decisions, or Advance Decisions to Refuse Treatment (short: 'ADRT') have a legal standing under the UK Mental Capacity Act (2005). They can be written down and signed by patients. Such an ADRT must be specific about the treatment that is being refused and the circumstances in which the refusal will apply. To be valid, the person must have been competent and understood the decision when they signed the ADRT. Where the patient's advance decision relates to a refusal of potentially life-saving or life prolonging treatment, this must be recorded in writing and witnessed. Any advance refusal is legally binding, providing that the patient is an adult, the patient was competent and properly informed when reaching the prior decision. It is clearly applicable to the present circumstances and there is no reason to believe that the patient has changed their mind. If an advance decision does not meet these criteria but appears to set out a clear indication of the patient's wishes, it will not be legally binding but should be taken into consideration in determining the patient's best interests. An example of an ADRT is the national form and guidance published by NHS Wales on their Advance and Future Care Planning site. [50]

Benefits

Research conducted in Switzerland with people aged 71 to 80 showed that better knowledge on advance care planning dispositions could improve the perception older people have of them. Communication on dispositions should take into account individual knowledge levels and address commonly enunciated barriers that seem to diminish with increased knowledge. [4]

Adults with heart failure

Advance care planning (ACP) may help to increase documentation by medical staff regarding discussions with participants, and improve an individual's depression. [51] This involves discussing an individual's future care plan in consideration of the individual's preferences and values. The findings are however, based on low-quality evidence as there is a need for further evidence from large studies to fully explore the effects of ACP for older adults. [51]

Older people with frailty

Advance care planning can effectively support older people with frailty to express what kind of healthcare they would prefer in the future. It can also improve the outcomes of healthcare received by elderly with frailty. [5] [52]

Related Research Articles

Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ... [It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research." The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.

<span class="mw-page-title-main">Advance healthcare directive</span> Legal document

An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S. it has a legal status in itself, whereas in some countries it is legally persuasive without being a legal document.

<span class="mw-page-title-main">Do not resuscitate</span> Legal order saying not to perform CPR if heart stops

A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on the jurisdiction, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary in different polities. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.

Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include the respect for autonomy, non-maleficence, beneficence, and justice. Such tenets may allow doctors, care providers, and families to create a treatment plan and work towards the same common goal. These four values are not ranked in order of importance or relevance and they all encompass values pertaining to medical ethics. However, a conflict may arise leading to the need for hierarchy in an ethical system, such that some moral elements overrule others with the purpose of applying the best moral judgement to a difficult medical situation. Medical ethics is particularly relevant in decisions regarding involuntary treatment and involuntary commitment.

<span class="mw-page-title-main">Cochrane (organisation)</span> British nonprofit for reviews of medical research (formed 1993)

Cochrane is a British international charitable organisation formed to synthesize medical research findings to facilitate evidence-based choices about health interventions involving health professionals, patients and policy makers. It includes 53 review groups that are based at research institutions worldwide. Cochrane has over 37,000 volunteer experts from around the world.

Palliative care is an interdisciplinary medical caregiving approach aimed at optimising quality of life and mitigating or reducing suffering among people with serious, complex, and often terminal illnesses. Many definitions of palliative care exist.

A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care provider.

In medicine, specifically in end-of-life care, palliative sedation is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.

Terminal illness or end-stage disease is a disease that cannot be cured or adequately treated and is expected to result in the death of the patient. This term is more commonly used for progressive diseases such as cancer, rather than fatal injury. In popular use, it indicates a disease that will progress until death with near absolute certainty, regardless of treatment. A patient who has such an illness may be referred to as a terminal patient, terminally ill or simply as being terminal. There is no standardized life expectancy for a patient to be considered terminal, although it is generally months or less. An illness which is lifelong but not fatal is called a chronic condition.

The Patient Self-Determination Act (PSDA) was passed by the United States Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990. Effective on December 1, 1991, this legislation required many hospitals, nursing homes, home health agencies, hospice providers, health maintenance organizations (HMOs), and other health care institutions to provide information about advance health care directives to adult patients upon their admission to the healthcare facility. This law does not apply to individual physicians.

A nurse-led clinic is any outpatient clinic that is run or managed by registered nurses, usually nurse practitioners or Clinical Nurse Specialists in the UK. Nurse-led clinics have assumed distinct roles over the years, and examples exist within hospital outpatient departments, public health clinics and independent practice environments.

In the field of medicine, a healthcare proxy is a document with which a patient appoints an agent to legally make healthcare decisions on behalf of the patient, when the patient is incapable of making and executing the healthcare decisions stipulated in the proxy. Once the healthcare proxy is effective, the agent continues making healthcare decisions as long as the primary individual is legally competent to decide. Moreover, in legal-administrative functions, the healthcare proxy is a legal instrument akin to a "springing" healthcare power of attorney. The proxy must declare the healthcare agent who will gain durable power attorney. This document also notifies of the authority given from the principal to the agent and states the limitations of this authority.

End-of-life care (EOLC) is health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotional needs, physical comfort, spiritual needs, and practical tasks.

The Liverpool Care Pathway for the Dying Patient (LCP) was a care pathway in the United Kingdom covering palliative care options for patients in the final days or hours of life. It was developed to help doctors and nurses provide quality end-of-life care, to transfer quality end-of-life care from the hospice to hospital setting. The LCP is no longer in routine use after public concerns regarding its nature. Alternative methodologies for Advance care planning are now in place to ensure patients are able to have dignity in their final hours of life. Hospitals were also provided cash incentives to achieve targets for the number of patients placed on the LCP.

SOCRATES is a mnemonic acronym used by emergency medical services, physicians, nurses, and other health professionals to evaluate the nature of pain that a patient is experiencing.

A surrogate decision maker, also known as a health care proxy or as agents, is an advocate for incompetent patients. If a patient is unable to make decisions for themselves about personal care, a surrogate agent must make decisions for them. If there is a durable power of attorney for health care, the agent appointed by that document is authorized to make health care decisions within the scope of authority granted by the document. If people have court-appointed guardians with authority to make health care decisions, the guardian is the authorized surrogate.

POLST is an approach to improving end-of-life care in the United States, encouraging providers to speak with the severely ill and create specific medical orders to be honored by health care workers during a medical crisis. POLST began in Oregon in 1991 and currently exists in 46 states, British Columbia, and South Korea. The POLST document is a standardized, portable, brightly colored single page medical order that documents a conversation between a provider and an individual with a serious illness or frailty towards the end of life. A POLST form allows emergency medical services to provide treatment that the individual prefers before possibly transporting to an emergency facility.

Abortion in Uganda is illegal unless performed by a licensed medical doctor in a situation where the woman's life is deemed to be at risk.

<span class="mw-page-title-main">Harvey Chochinov</span> Canadian academic and psychiatrist

Harvey Max Chochinov is a Canadian academic and psychiatrist from Winnipeg, Canada. He is a leading authority on the emotional dimensions of end-of-life, and on supportive and palliative care. He is a Distinguished Professor of Psychiatry at the University of Manitoba and a Senior Scientist at CancerCare Manitoba Research Institute.

ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. It is an emergency care and treatment plan (ECTP) used in parts of the United Kingdom, in which personalized recommendations for future emergency clinical care and treatment are created through discussion between health care professionals and a person. These recommendations are then documented on a ReSPECT form.

References

  1. 1 2 Rietjens, Judith; et al. (September 2017). "Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care" (PDF). The Lancet. 18 (9): E543 –E551. doi:10.1016/S1470-2045(17)30582-X. PMID   28884703.
  2. 1 2 3 4 "A National Framework for Advance Care Directives" (PDF). Australian Health Ministers' Advisory Council. September 2011. Archived from the original (PDF) on 26 January 2014. Retrieved 17 December 2013.
  3. 1 2 Detering KM, Hancock AD, Reade MC, Silvester W (March 2010). "The impact of advance care planning on end of life care in elderly patients: randomised controlled trial". BMJ. 340. BMJ Publishing Group Ltd: c1345. doi:10.1136/bmj.c1345. PMC   2844949 . PMID   20332506.
  4. 1 2 Cattagni Kleiner A, Santos-Eggimann B, Fustinoni S, Dürst AV, Haunreiter K, Rubli-Truchard E, Seematter-Bagnoud L (April 2019). "Advance care planning dispositions: the relationship between knowledge and perception". BMC Geriatrics. 19 (1): 118. doi: 10.1186/s12877-019-1113-3 . PMC   6480869 . PMID   31014271.
  5. 1 2 Hopkins, Sarah A; Bentley, Allison; Phillips, Veronica; Barclay, Stephen (27 May 2020). "Advance care plans and hospitalized frail older adults: a systematic review". BMJ Supportive & Palliative Care. 10 (2): 164–174. doi:10.1136/bmjspcare-2019-002093. ISSN   2045-435X. PMC   7286036 . PMID   32241957.
  6. ↑ Rietjens, Judith; et al. (18 February 2021). "Advance Care Planning: the future". BMJ Supportive & Palliative Care. 11 (1): 89–91. doi:10.1136/bmjspcare-2020-002304. PMID   32414786.
  7. ↑ "NHS Scotland: Future Care Planning". NHS Inform Scotland. 25 January 2024. Retrieved 11 February 2024.
  8. ↑ Taubert, Mark; et al. (1 February 2022). "Advance and Future Care Planning: strategic approaches in Wales". BMJ Supportive & Palliative Care. 14: e608 –e612. doi: 10.1136/bmjspcare-2021-003498 . PMID   35105552.
  9. ↑ "Gold Standard Framework - Advance Care Planning". www.goldstandardsframework.org.uk. Retrieved 2024-08-19.
  10. ↑ Simón, P. (2011-06-01). "Use of advance care planning – a European perspective". BMJ Supportive & Palliative Care. 1 (1): 75–76. doi:10.1136/bmjspcare-2011-000053.35. ISSN   2045-435X.
  11. ↑ "Respecting Patient Choices". Advance Care Planning Australia. Archived from the original on 2014-01-26. Retrieved 18 December 2013.
  12. ↑ "Competence and Capacity". Advance Care Planning Australia. Archived from the original on 2014-01-26. Retrieved 18 December 2013.
  13. ↑ "The benefits of advance care planning". Advance Care Planning Australia. Archived from the original on 2014-01-26. Retrieved 16 December 2013.
  14. 1 2 Aslakson RA, Schuster AL, Reardon J, Lynch T, Suarez-Cuervo C, Miller JA, et al. (November 2015). "Promoting perioperative advance care planning: a systematic review of advance care planning decision aids". Journal of Comparative Effectiveness Research. 4 (6): 615–50. doi:10.2217/cer.15.43. PMID   26346494.
  15. ↑ Silveira MJ, Kim SY, Langa KM (April 2010). "Advance directives and outcomes of surrogate decision making before death". The New England Journal of Medicine. 362 (13). Massachusetts Medical Society: 1211–8. doi:10.1056/NEJMsa0907901. PMC   2880881 . PMID   20357283.
  16. ↑ Kim P, Daly JM, Berry-Stoelzle MA, Schmidt ME, Michaels LC, Dorr DA, Levy BT (2020-03-01). "Prognostic Indices for Advance Care Planning in Primary Care: A Scoping Review". Journal of the American Board of Family Medicine. 33 (2): 322–338. doi:10.3122/jabfm.2020.02.190173. PMC   7772823 . PMID   32179616.
  17. ↑ Winzelberg GS, Hanson LC, Tulsky JA (June 2005). "Beyond autonomy: diversifying end-of-life decision-making approaches to serve patients and families". Journal of the American Geriatrics Society. 53 (6). American Geriatrics Society: 1046–50. doi:10.1111/j.1532-5415.2005.53317.x. PMID   15935032. S2CID   13297057.
  18. ↑ Cartwright CM, Parker MH (October 2004). "Advance care planning and end of life decision making". Australian Family Physician. 33 (10). Royal Australian College of General Practitioners: 815–9. PMID   15532156.
  19. ↑ "Your rights and choices as a patient". Dying with Dignity. 2011. Archived from the original on 11 October 2014. Retrieved 9 October 2014.
  20. ↑ Mullick A, Martin J, Sallnow L (October 2013). "An introduction to advance care planning in practice". BMJ. 347. BMJ Publishing Group Ltd: f6064. doi:10.1136/bmj.f6064. PMID   24144870. S2CID   29973911.
  21. ↑ Çevik, Hüsna Sarıca; Muente, Catharina; Muehlensiepen, Felix; Birtwistle, Jacqueline; Pachanov, Alexander; Pieper, Dawid; Allsop, Matthew J. (2024-05-03). "Systems for electronic documentation and sharing of advance care planning preferences: a scoping review". Progress in Palliative Care. 32 (3): 149–159. doi:10.1080/09699260.2024.2339106. ISSN   0969-9260. PMC   11145469 . PMID   38831759.
  22. ↑ Birtwistle, Jacqueline; Millares-Martin, Pablo; Evans, Catherine J.; Foy, Robbie; Relton, Samuel; Richards, Suzanne; Sleeman, Katherine E.; Twiddy, Maureen; Bennett, Michael I.; Allsop, Matthew J. (2022-10-14). "Mapping and characterising electronic palliative care coordination systems and their intended impact: A national survey of end-of-life care commissioners". PLOS ONE. 17 (10): e0275991. Bibcode:2022PLoSO..1775991B. doi: 10.1371/journal.pone.0275991 . ISSN   1932-6203. PMC   9565729 . PMID   36240254.
  23. ↑ Bradshaw, Andy; Birtwistle, Jacqueline; Evans, Catherine J.; Sleeman, Katherine E.; Richards, Suzanne; Foy, Robbie; Martin, Pablo Millares; Carder, Paul; Allsop, Matthew J.; Twiddy, Maureen (2024-08-16). "Factors Influencing the Implementation of Digital Advance Care Planning: Qualitative Interview Study". Journal of Medical Internet Research. 26 (1): e50217. doi: 10.2196/50217 . PMID   39151167.
  24. ↑ Birtwistle, Jacqueline; Allsop, Matthew J; Bradshaw, Andy; Millares Martin, Pablo; Sleeman, Katherine E; Twiddy, Maureen; Evans, Catherine J (July 2024). "Views of patients with progressive illness and carers about the role of digital advance care planning systems to record and share information: A qualitative study". Palliative Medicine. 38 (7): 711–724. doi:10.1177/02692163241255511. ISSN   0269-2163. PMC   11290031 . PMID   38813756.
  25. 1 2 "Choosing someone to speak for you". Advance Care Planning Australia. 19 December 2013. Archived from the original on 2014-01-26.
  26. ↑ "Substitute Decision Maker". Advance Care Planning Australia. Archived from the original on 2014-01-26. Retrieved 18 December 2013.
  27. ↑ "Substitute Decision-Makers: End-of-Life Decision-Making when the Patient is Incapable". Caring to the end of life - Princess Margaret Hospital University Health Network. Archived from the original on 2014-07-26. Retrieved 16 December 2013.
  28. ↑ "Enduring Power of Attorney". Public Advocate of the ACT. 20 July 2011. Retrieved 17 December 2013.
  29. ↑ "Enduring Guardianship". New South Wales Government, Guardian Tribunal. 7 August 2012. Retrieved 17 December 2013.
  30. ↑ "Enduring Power of Attorney". Queensland Government. 22 February 2013. Retrieved 17 December 2013.
  31. ↑ "Medical Power of Attorney and Anticipatory Direction". Government of South Australia, SA Health. 12 October 2013. Retrieved 17 December 2013.
  32. ↑ "Enduring guardianship". Tasmanian Government, Guardianship and Administration Board. 30 July 2013. Retrieved 17 December 2013.
  33. ↑ "Medical Treatment Decision Makers". Office of the Public Advocate Victoria. Retrieved 4 October 2021.
  34. ↑ "Enduring Power of Giardianship (EPG)". Government of Western Australia, Office of the Public Advocate. Retrieved 18 December 2013.
  35. ↑ "Lasting power of attorney". GOV.UK. 8 November 2013. Retrieved 17 December 2013.
  36. ↑ "It's your decision: how to make an advance health care directive" (PDF). NF&L Government, Department of Health and Community Services and Department of Justice. Archived from the original (PDF) on 18 April 2013. Retrieved 9 Oct 2014.
  37. ↑ "Personal directives in Nova Scotia" (PDF). novascotia.ca. Retrieved 9 Oct 2014.
  38. ↑ "Wills and estate planning". Public Legal education and information service of New Brunswick. Retrieved 9 Oct 2014.
  39. ↑ "Health Care Directives" (PDF). Community legal information association of PEI. Retrieved 9 Oct 2014.
  40. ↑ "My mandate in case of incapacity". Curateur Public Quebec. Retrieved 9 Oct 2014.
  41. ↑ "Power of Attorney for Personal Care". Community Legal Education Ontario. Retrieved 9 Oct 2014.
  42. ↑ "Health Care Directive". gov.mb.ca. Retrieved 9 Oct 2014.
  43. ↑ "The Health Care Directives and Substitute Health Care Decision Makers Act". justice.gov.sk.ca. Archived from the original on 2014-10-15. Retrieved 9 Oct 2014.
  44. ↑ "Understanding Personal Directives" (PDF). Government of Alberta. Retrieved 9 Oct 2014.
  45. ↑ "Health Care (Consent) and Care Facility (Admission) Act". BC laws.ca. Retrieved 9 Oct 2014.
  46. ↑ "Advance Directives". Yukon Health Guide. Archived from the original on 2013-05-19. Retrieved 9 Oct 2014.
  47. ↑ "Personal Directives" (PDF). NWT Health and Social services. Archived from the original (PDF) on 15 October 2014. Retrieved 9 Oct 2014.
  48. ↑ "Advance Care Planning". NSW Office for Ageing, NSW Trustee and Guardian and NSW Public Guardian. Archived from the original on 15 December 2013. Retrieved 18 December 2013.
  49. ↑ "Writing down your wishes". Advance Care Planning Australia. Archived from the original on 26 January 2014. Retrieved 18 December 2013.
  50. ↑ "Advance and Future Care Plans". NHS Wales Executive. 12 January 2022. Retrieved 12 January 2024.
  51. 1 2 Nishikawa Y, Hiroyama N, Fukahori H, Ota E, Mizuno A, Miyashita M, et al. (Cochrane Heart Group) (February 2020). "Advance care planning for adults with heart failure". The Cochrane Database of Systematic Reviews. 2020 (2): CD013022. doi:10.1002/14651858.CD013022.pub2. PMC   7045766 . PMID   32104908.
  52. ↑ Wang, Xinying; Huang, Xin-Lin; Wang, Wei-Jia; Liao, Li (May 2023). "Advance care planning for frail elderly: are we missing a golden opportunity? A mixed-method systematic review and meta-analysis". BMJ Open. 13 (5): e068130. doi:10.1136/bmjopen-2022-068130. ISSN   2044-6055. PMC   10230943 . PMID   37247960.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.