Advance Care Planning – Why do we care?

By Annie Zhu, Student Leadership Team Multimedia Specialist

Canada’s Aging Population

Next year, the number of seniors aged 65 and older will be greater than the number of children under the age of 15 in Canada. In 50 years, seniors will account for almost a quarter of the population.(1) As the population ages, hospitalization rates and drugs will play an increasingly significant role in shaping healthcare costs. 40% of health care spending goes toward those 65 and older in Canada despite this age group accounting for less than 20% of the total Canadian population. Additionally, 20% of total healthcare spending occurs during the last years of life in Canada because of expensive and costly diagnostic care, technology assisted monitoring and ICU treatment. (2) As the population ages, these costs will increase and place a bigger burden on Canada’s healthcare system.

End of life care in Canada at a glance

  • Only ¼ of Canadians over 30 years of age have made end of life care plans (3)
  • Only 16-30% of Canadians have access to high-quality palliative care (3)
  • Only half of the Canadian population have had a discussion with a family member or friend about end-of-life care wishes (3)
  • 86% of Canadians have not heard of advance care planning (3)

What is Advanced Care Planning (ACP)?

ACP is a process where individuals communicate their end of life (EOL) wishes to their health care providers and their families, and plan for a time when they may not be able to make informed medical decisions in the future.(4) One of the difficulties in EOL care provision is determining patient preferences. When completing ACP, most patients would prefer their EOL experience to occur at home, yet rates of hospital deaths and intrusive maneuvers such as cardiopulmonary resuscitation are increasing in Canada, which suggests increased life-support usage during EOL.(5,6) This demonstrates a discordance between patient interests and healthcare provision. Increasing usage of and adherence to ACP wishes of patients could be a potential solution based on existing evidence of its effectiveness and feasibility.

Systematic reviews have explored the impact of various ACP interventions, such as increasing communication about ACP and increasing EOL care decisions between patients and healthcare professions, on patient usage of ACP. These interventions have been reported to improve completion of advance directives and EOL care discussions, leading to concordance between patient’s preferences and the EOL care received.(7) Interventions can also improve the quality of communication between patients and their loved ones.(7)  While the effects of ACP on patient satisfaction and EOL care preferences are unknown, more research is currently being conducted to answer these questions.

Furthermore, implementing ACP in hospitals has been found to be cost-effective. The cost of life-sustaining technologies is expensive and patients often prefer care that emphasizes comfort. One study examined the use of ACP to costs saved and found that the aggregate cost of care for patients with ACP was 35.7% lower than patients with no ACP, resulting in a difference of $1041 USD saved per year.(8) Additionally, another systematic review concluded that patients who received ACP or palliative care interventions showed a pattern towards decreased ICU admissions and reduced ICU length of stay.(9) These studies provide a model for how increased uptake of ACP can reduce healthcare costs.

Conclusion

ACP is a relatively simple intervention and 80% of Canadians report that they are comfortable talking about their EOL care and related issues.(3) Discussing and recording EOL care wishes can benefit the healthcare system, patients, and families. Current evidence suggests that implementing ACP can reduce total healthcare costs and provide greater concordance between patients’ wishes and healthcare provided.

References

  1. Statcan.gc.ca. The Daily — Canada’s population estimates: Age and sex, 2014 [Internet]. 2014 [cited 6 November 2015]. Available from: http://www.statcan.gc.ca/daily-quotidien/140926/dq140926b-eng.htm
  2. Fowler R, Hammer M. End-of-life care in Canada. Clinical & Investigative Medicine. 2013;36(3):127-132.
  3. Ontariosdoctors.com. About End of Life Care | Ontario’s Doctors [Internet]. 2015 [cited 4 November 2015]. Available from: http://www.ontariosdoctors.com/keeping-you-healthy/end-of-life-care/about-end-of-life-care/
  4. Sinuff T, Dodek P, You J, Barwich D, Tayler C, Downar J et al. Improving End-of-Life Communication and Decision-Making: The Development of a Conceptual Framework and Quality Indicators. Journal of Pain and Symptom Management. 2015;.
  5. Teixeira A, Hanvey L, Tayler C, Barwich D, Baxter S, Heyland D. What do Canadians think of advanced care planning? Findings from an online opinion poll. BMJ Supportive & Palliative Care. 2013;.
  6. Heyland D, Lavery J, Tranmer J, Shortt S, Taylor S. Dying in Canada: is it an institutionalized, technologically supported experience?. Journal of Palliative Care. 2000;16:S10-6.
  7. Houben C, Spruit M, Groenen M, Wouters E, Janssen D. Efficacy of Advance Care Planning: A Systematic Review and Meta-Analysis. Journal of the American Medical Directors Association. 2014;15(7):477-489.
  8. Zhang B, Wright A, Huskamp H, Nilsson M, Maciejewski M, Earle C et al. Health Care Costs in the Last Week of Life. Archives of Internal Medicine. 2009;169(5):480.
  9. Khandelwal N, Kross E, Engelberg R, Coe N, Long A, Curtis J. Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization. Critical Care Medicine. 2015;43(5):1102-1111
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s