Key considerations: Advance Care Planning and AD

CALD Older People Resource

ACP is a voluntary process of discussion and shared planning for future health care.
An AD is consent or refusal of specific treatment(s) offered in the future when the person does not have capacity.
EPA - People aged 18 or over can formally appoint a person or people to act on their behalf. The person who acts on the appointee's behalf is known as an ‘attorney'. The form /document used to appoint the attorney is known as ‘power of attorney' (EPA).

It is important to avoid stereotyping Asian, Middle Eastern or African patients as having the same worldviews

Chinese families may have difficulty conceptualising ACP. Longevity is more important than the quality of life.
Families’ protection of elders may result in their not informing their family member of a serious diagnosis to protect them; which means that they are unlikely to want to discuss ACP with their older family member.
Traditional Chinese families do not like discussing taboo subjects such as death, dying and cancer.
Physician- and family-based decision making is preferred over patient autonomy.
Chinese people may not necessarily see “home” as the place of care at the end-of-life. Hospitals can be seen as places with appropriate competent professional care. The use of community hospices can also be encouraged.
There may be resistance towards organ donation. This may result from a wish to keep the body whole for the afterlife, and out of respect.

Traditional Korean families consider family-based medical decisions as a function of filial piety. Illness is considered a family event, rather than an individual occurrence (Searight, 2005).
Family leaders are traditionally expected to be the decision makers, e.g. the husband or the eldest son. There tends to be an orientation toward the extended family as opposed to individual patient self interest.
It is important for health professionals to understand why Koreans may not make clear decisions about ACP or end of life care, and why they often change their minds.

Traditional South Asian families value physician- and family-based decision making over autonomy. Caring for the sick and dying is the duty of the family.
The avoidance of contemplating serious ill health and death presents a barrier to the discussion of ACP in Asian families (Lip, 2009).

Not all Muslim families are familiar with advance directives or advance planning. There should be a discussion on AD with members of the family and expressed wishes should be recorded.

Culturally appropriate ACP

When the family has been nominated by the patient as the designated decision maker on health care issues, any ACP discussion should include the family.
Sufficient time must be allocated for discussion, which must be in private.
Determine if the client and family understand the purpose of an ACP.
Provide detailed information including the natural course of the disease, the prognosis, and the chance of survival. When the client or family wants “everything possible done”, an exploration of what that means can provide a greater understanding of what is behind the request.
Clients and family members need to be assured that an ACP that excludes curative treatment does not mean the client will be abandoned by the health care system.
A religious leader can play an important role in facilitating the discussion and decision-making process in ACP through clarification of how certain aspects of a religion's principles or beliefs may influence the decision on providing life support measures.
More subtle, indirect and implicit non-verbal communication may be preferred when discussing ACP. Non-verbal communication includes active listening with pauses between sentences, silence, and where appropriate physical contact such as holding the patient’s hand.