Meredith Blake

Advance care planning for people with dementia in Western Australia: An examination of the fit between the law and practice

Abstract This article examines the ‘fit’ between the Western Australian legislation on advance care planning (ACP) and health professionals’ experiences implementing this in relation to persons with dementia. The legislative provisions are outlined, and a qualitative study of experiences with ACP among 19 health professionals, all engaged in the care of persons with dementia, is described. Based on these interviews, the authors propose three themes: ‘navigating risk’, ‘the therapeutic journey’ and ‘the most agreeable outcome’ to describe current practice in this area. The authors conclude that ACP in this context is aimed at minimising risk, establishing consensus and achieving the ‘most agreeable outcome’ for the person and their family, rather than privileging the individual autonomy of the person engaging in ACP. The implications for policy and law makers regarding possible reform of ACP in relation to persons with dementia are discussed.

O-27 Promoting autonomy? Bringing legal analysis to bear on the practical issues associated with ACP implementation

Background Advance care planning (ACP) legislation aims to promote patient autonomy, however there are practical challenges in implementing ACP in healthcare settings. Aim This study applied legal analysis to an initiative aimed at implementing ACP in one residential aged care facility (RACF). Methods Case study of a quality improvement initiative, with concurrent legal analysis. The research team and RACF staff (N = 10) collaborated over a year, documenting practical challenges in implementing ACP. Quality improvement methodology was used to develop and trial solutions. Research data included an ‘end-of-life wishes conversation tool’, staff meeting minutes and resident/family outcomes (satisfaction with conversation tool, number of completed ACP discussions, retrospective audit of end-of-life care). Results Challenges included staff turnover, high rates of dementia, and difficulties coordinating meetings with family members. Residents, family members and staff rated the ‘end of life wishes conversation tool’ positively. Where residents lacked capacity due to dementia, a substitute decision-making approach was adopted, with reliance on family members. However staff lacked a robust process for assessing capacity to participate in ACP. Discussion Implementing ACP in the RACF setting can be problematic. Dementia can erode resident autonomy, and force staff to adopt a substitute decision-making approach, particularly when under time pressure. Quality improvement projects provide rich, contextual data regarding practical challenges, while legal analysis interprets these challenges with reference to intentions underpinning ACP legislation. Conclusion Further work is required to support decision-making capacity for RACF residents with dementia. This will enable ACP legislation to achieve its aims of promoting patient autonomy.