A patient’s wishes — and life-or-death treatment decisions

A pilot study at a busy Melbourne hospital has revealed that many people who present to the emergency department do not have an Advance Care Directive (ACD) — a document that details a patient’s preferences for treatment if they are unable to make decisions for themselves.

The research also highlights the issues confronting emergency clinical staff who often need to make split-second treatment decisions for patients with cognitive impairment.

Federation University researcher Dr Abdi Osman, who is a Scholarly Teaching Fellow in the School of Health and has a background in emergency nursing, said the idea for the study came about because emergency department staff routinely moved quickly to treat patients who require emergency medical treatment, sometimes without considering their wishes.

“Most of the time, we just don't have that information regarding the dos and don’ts for life-saving treatment handy, and that will drive us to carry on and do whatever we can for the patient,” Dr Osman said.

“It dawned on me that there were a lot of shortcomings in this area, so I started looking into Advance Care Directives and more broadly at advanced care practices across Australia.”

The Austin is also home to Advanced Care Planning Australia’s national office, allowing Dr Osman and the researchers to look at the broader prevalence and implementation of the directives. In March 2018, the Medical Treatment Planning and Decisions Act 2016 was implemented in Victoria, creating clear obligations for health practitioners who cared for patients who lack decision-making capacity.

Despite the new framework, Dr Osman said many clinicians in Victoria were still unaware of the Act as the researchers kicked off the study in early 2019.

“This is when we started looking at the prevalence of Advance Care Directives among our patients. According to Advance Care Planning Australia, people 65 and over are expected to have an ACD in place, so this pilot study looked at all the patients who presented to the emergency department in that demographic and whether they had a directive,” Dr Osman said.

“The findings weren’t pleasing because the prevalence was very low. We found in a single centre study that an Advance Care Directive was present for only 8 per cent of our patients against a reported national prevalence of 29 per cent of over 65s having an ACD.”  Dr Abdi Osman

Dr Osman said these findings were presented to the hospital’s emergency department executives, who had invited the researchers to find long-lasting solutions for advanced care planning. A special interest group called ACED (Advance Care in the Emergency Department) was formed and included doctors, nurses and other clinical staff, and a research arm.

The group’s work will include undertaking further research, planning for interventions based on the research findings that will include easy access to ACD documents, implementing ACD preferences in line with the Act, consent seeking process for patients lacking cognitive capability and ACD documentation in line with the Act.

The researchers hope to draw attention to ACDs to all people 65 and over, and the medical professionals who treat them in the country’s emergency departments and the larger acute healthcare facilities.  The researchers also hope to replicate the study in a regional setting.

“With increasing longevity in life, there are a great number of people aged 65 or over who lose their cognitive capability.  Ethical and legal issues come into play because people in this position cannot consent to treatment, but we go ahead with the treatment in the hope of serving their best interests, but often, we’re not sure if this is according to their wishes,” Dr Osman said.

“It’s a problem nationally. It’s not just Victoria and what makes it more complex is that the states are not unified — every jurisdiction does it their way. We really should be aiming for a national outlook.”