Advance Care Planning – good for patient care and better use of health dollars?

By Public Health Expert 14/10/2013 3


Dr Ben Gray, General Practitioner, Primary Health Care & General Practice Department, University of Otago, Wellington

Dr Ben Gray

Advance Care Planning (or ACP) is the process of thinking about, talking about and planning for future health care and end of life care. In its delivery, this seems a very clinically focussed, individual health care process, so what relevance has it got for Public Health?

Actually a lot. We know that we spend around seven times more in the last year of life than the average spent in all other years of a patient’s life (2). This problem will be exacerbated as the baby boomers die.

Expenditure on dying people is going to rise. However Advanced Care Planning can potentially minimise this rise in health expenditure, saving health dollars for use elsewhere in the system as well as improving patient quality of life.

Advance Care Planning has been introduced because it has been recognised that collectively the health system is not good at doing “informed consent” around the end of life. There are two important reasons for this. The first is well illustrated by my patient Joan (fictitious name).

“From 30,000 deaths in 2012, it is highly likely that deaths will exceed 40,000 in 2036. It is highly likely deaths will exceed 50,000 after 2051” (3)

Joan lived alone in a small council apartment. She suffered from emphysema and had been unable to stop smoking. Her world slowly shrunk as she got more breathless. First she had to give up gardening. Slowly she had more difficulty getting around her apartment. She would have exacerbations requiring antibiotics but we managed to keep her away from hospital. Eventually despite 24 hour oxygen she decided she could not manage at home anymore and was admitted to a rest home. I remember visiting her there and her telling me that she really did not want to be there and that there was not much for her to live for. Two weeks later she became unwell over the weekend and was admitted to hospital with a chest infection. I visited her on Monday afternoon. I saw her in her 4 bedded cubicle and she said in a loud but very breathless voice “I don’t want to live anymore.” I asked the staff what treatment she was on and found that they were giving her antibiotics for the chest infection. When I asked her if she wanted that she said no. The antibiotics were stopped and she died a day later. No one at the hospital had been able to have the conversation with her about whether she wanted treatment or not.

Source of picture http://www.advancecareplanning.org.nz/personal/

The second reason we need to improve end of life care is to do with the fact that if you have a hammer then “everything looks like a nail”. If you visit a surgeon or oncologist with a cancer they will offer treatment. Sometimes they offer treatment as a last chance without even giving any idea of how big that chance might be. It even turns out that some people live longer if given palliative care than if offered interventional care (4). If a patient had thought of and discussed their wishes in the last phase of life they would be in a better position to question their clinicians to find out why they were proposing treatment and what the benefit of treatment would be. As long as a clinician’s presumptions that extending life at any cost is worth it goes unchallenged, ineffective intervention is more likely to continue. This issue of “futile care” is well summarised by Botha et al (1).

The health sector is continually under financial pressure with endless calls for more expenditure. In the last few weeks there have been proposals for a bowel cancer screening programme, for more funding for low cost primary care clinics and for better wages for rest home workers – all potentially cost-effective or the right thing to do, but what gives? Prioritisation decisions are always hard. How would we weigh the relative merits of those three proposals, and what would we remove funding from in order to fund these?

Advance Care Planning has a great potential to save health sector dollars at the same time as improving patient care. If all the patients like Joan could have their wishes for less health sector resources provided, and we only offered treatment to patients that we knew would be likely to benefit, a lot of resource could be saved, making it easier to fund other deserving options like the ones above.

Last month the result of a national cooperative process was launched in the form of a website and a large amount of supporting material. There is an e-learning platform for clinicians, and information for patients and their families on how to go about having a conversation about how they want to live until they die. Personnel are being trained as trainers in Advance Care Planning. This is an important initiative. The ground work has been done well and it is now up to all of us, planners, clinicians and the public as a whole to embrace the idea and give it a good run (with future evaluations being of course critical). Whoever thought that something as simple as a conversation had the potential to make such a difference?

References:

1. Botha, J., Tiruvoipati, R., & Goldberg, D. (2013). Futility of medical treatment in current medical practice. New Zealand Medical Journal, 126(1383).

2. Chan, W. C., Jackson, G., Winnard, D., & Anderson, P. (2011). Healthcare services funded by Counties Manukau District Health Board for people in the last year of life. Journal of the New Zealand Medical Association, 124(1335).

3. Statistics New Zealand. (2011). National Population Projections.

4. Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., …Lynch, T. J. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. New England Journal of Medicine, 363(8), 733-742. doi: doi:10.1056/NEJMoa1000678

 


3 Responses to “Advance Care Planning – good for patient care and better use of health dollars?”

  • While this syndicated post by Dr Ben Gray may on one hand make some sense and seems reasonable, there is another side to it that should give rise to concerns. Persons and patients change their views based on ongoing life experiences, and the nearer they get to their final year, their thinking may change substantially. Advance Care Planning must be applied by giving consideration to this, and to allow patients to adjust their advanced planning. Also must it be ensured that independence in developing decisions and plans exist, and that no agency or person is allowed to influence this for mere cost saving motivations.

    I say this in view of the fact that Dr Gray is also known to be a staunch supporter of recent welfare reforms by the present government, putting very high “work capability expectations” on sick and disabled with work incapacity, who are supported by welfare benefits. He is following the teachings by a controversial professor Mansel Aylward who conducted “research” at a Unum Provident “sponsored” department at Cardiff University in Wales, who developed his somewhat perverted a “bio-psycho-social model” for assessments and treatments of sick and disabled, thereby basically serving the interests of insurance companies and governments, to save costs by getting sick and disabled off benefits.

    That approach led to over 1,100 deaths in the UK in 2011, being persons who could not cope with wrongly assessed work capability and died early, or even committed suicide (particularly mental health sufferers).

    Dr Gray sat on the ‘Health and Disability Board’ that advised MSD and Minister Paula Bennett, and he was one of the hand-picked “experts”, who in their majority supported the government reforms, that have already been commented on critically in mainstream and social media. Especially a Principal Health Advisor for WINZ, Dr Bratt, has been criticised for likening benefit dependence with “drug dependence”.

    So I would be careful with any approaches that could compromise the Code of Ethics of medical and other practitioners, being perhaps pressured by government departments to deliver cost savings in areas like this.

    It is in the least a highly sensitive area, and needs to be treated with great caution, what is recommended here.

  • Mr Christian is absolutely right that advance care planning(http://www.advancecareplanning.org.nz/) is a process not an end point. People of course change their views and thinking does change. The point of the post was not that we should do this for “mere cost saving” but that there is an opportunity that if we do advance care planning well, leading to better outcomes for patients this may also save some money that can be better spent within the rest of the health system. If he looked through the material on the advance care planning website I hope he would be encouraged that the goals he is espousing are imbedded in this New Zealand developed initiative.

    Mr Christian’s interpretation of my views on welfare reform are not factually based. I have not read the teachings of Mansel Aylward so it is pretty hard for me to follow them. The benefit system that was being reformed had been in place since the 1960’s and needed updating. He seems to think that keeping “sick and disabled” on benefits is a good thing. The expert Advisory group was very conscious of the failed experiment in the UK and there are significant differences from the system in the UK and that in New Zealand.

    Paula Bennett could be applauded for even appointing me to her expert advisory group. I have worked serving the severely disadvantaged people in our community for the last 30 years and been an important part of the team at Newtown Union Health Service that has been a leader in providing health care for these people. In no way could I be seen as a supporter of this governments general direction. I too am distressed at the gap between the direction of the policy, which I largely approve of, and implementation which is on too many occasions callous and uncaring. I continue to advocate for my patients to be well served by Work and Income. I am prepared to do my bit to try to make a difference.

  • Thank you for your comment, Dr Ben Gray.

    Well, that website is presented almost like a nice insurance brochure, I must say, and all that well worded, seemingly well intended information may at first glance convince many.

    I have seen and read a fair bit, and while I may agree there are possibly benefits if it is applied correctly and fairly, I continue to have my concerns. So funding has for the initial work been provided by Health Workforce NZ, a “business unit” of the National Health Board, which has Professor Des Gorman as chairman of their board.

    I have read and heard about Dr Gorman over many years, know of his involvement with ACC, and how some of his recommendations on disabled and injured have been highly controversial. Now apart from that, it is clear that funding will in one form or another come from central government.

    We have the same in welfare, and the government will in that area outsource more services to private contractors soon, to deliver on anticipated outcomes. They will likely not be covered by the Official Information Act, and other legal obligations that WINZ comes under.

    I appreciate your clear position on welfare reforms and your involvement as advisor to Paula Bennett. I especially appreciate your clarification that you are not well informed on Professor Mansel Aylward and his “research findings”. It is much appreciated that you distance yourself from the way the present government and MSD are implementing the welfare reforms, as it is indeed scandalous what I have heard from some that are affected.

    Having a Dr David Bratt as Principal Health Advisor at MSD, who likens benefit dependence to “drug dependence”, and uses selected bits of questionable statistics, is a bit hard to stomach for some, and that is where my major concerns remain with that. See his presentation here, which you may be familiar with:

    http://www.gpcme.co.nz/pdf/GP%20CME/Friday/C1%201515%20Bratt-Hawker.pdf

    Regarding your proposed ‘Advance Care Planning’, I do sincerely hope that this will be applied with all the needed checks and balances. As the government is ultimately the main funding provider in healthcare in New Zealand, and also pays offices like the Health and Disability Commissioner (struggling to deal with cases), I will wait with interest, to see how it will be put into practice.

    Having government fund, deliver and also “check” on quality and standards for healthcare outcomes all at the same time can be a “tricky” undertaking.

    Best wishes, Marcus