ACD and the Older Patient

An Advance Care Directive (“ACD”) often referred to as a “Living Will” is a document stating the specific medical treatment that the patient does or does not wish to receive. In order to make an ACD a person must have legal capacity, and the medical treatment that they want to receive must be expressed in a clear and unambiguous way

An ACD enables you to set out the medical care you wish to receive when medical technology might be required to keep you alive. Importantly if you lack the capacity to make decisions about your medical treatment the person or persons you appoint as substitute decision-makers, family members and significant others must be informed with regard to your medical wishes

In the absence of an ACD consent for medical treatment must be considered on a case by case basis and may be given by:

  • the patient if they have legal capacity;
  • the patient’s guardian;
  • the spouse of the patient (if they have capacity),
  • by the patient’s carer;
  • or by a close friend or relative of the patient.

A persons capacity to make health care decisions must be carefully considered as what appears to be valid consent given by a capable adult may be the result of undue influence, or of some other circumstance.

Recently in the United States 393 patients all 65 or older with multiple illnesses, were involved in a study regarding their treatment preferences prior to undergoing risky surgery either planned or as an emergency.

Most surprising was that patients undergoing planned operations were as likely to have documented their wishes as those who had emergency surgeries.

Only about a quarter had advance care directives (ACD) outlining their preference for treatment options including whether they would like to receive life support and who should make medical decisions on their behalf, in the event they are unable to do so.

Patients aged over 85 were more likely to have prepared ACD than people aged 65 to 74. Those who made more frequent trips to the doctor and those diagnosed with mild cognitive impairment were also found to be more likely to have prepared an ACD.

When researchers followed up it was discovered that among those who died within a year after their operations, only 31% had prepared an advance care directive.

When contacted by researchers Doctors claimed that they often found it difficult to discuss an ACD feeling that they lack the training required to have that type of conversation with their patients. Others raised concerns that in discussing complications and death it took away some of the hope that patients had of undergoing a full recovery.

The paper found that there are often disagreements among loved ones who are overwhelmed when asked to make decisions about issues they haven’t discussed before. When patients don’t prepare an ACD their family often lack guidance at a time where they can be surprised and overwhelmed if asked to make decisions that they have not considered before. The study recommends that all older adults with multiple chronic conditions undergoing high-risk surgery would benefit from having advance care directives completed and documented in medical records.


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