Good Practices Overview | Basque Country | Czech Republic | Norrbotten | Puglia | Scotland

Care Planning in Integrated Care Organisation

Summary of the good practice:

Every human being is recognized with his or her right to make decisions regarding medical treatment, even when his/her level of competence is compromised by adverse health conditions. Advanced Care Planning (ACP) guarantees patients’ right both to make decisions as well as to have those decisions respected when time comes. The general goal of this program is to promote ACP, mainly for chronic patients.

The programme states two specific goals:

1) adjusting end of life care to meet patients’ preferences, and

2) improving decision making processes.

The program defines three stages:

  1. Diagnostic stage, aiming at identifying the population that could benefit from the program,
  2. Therapeutic stage, aiming at developing the intervention (after providing training opportunities for involved health professionals),
  3. Evaluative stage, aiming at assessing both the impact of the program and the program itself.

The core intervention at the heart of the program consists of two individual semi structured interviews with the patient and one or two significant others. Previous to these meetings patients invited to participate receive a document that intends to elicit reflections about health, care, quality of life and end of life. The interviews are initially conducted by the programme coordinator along with patient’s GP and Community Nurse. The program is intended to help clinicians become capable of conducting the interviews themselves.

The first meeting aims mainly at introducing the subject (Advanced Directives) and inviting the patient to reflect on his/her preferences regarding care. The second interview focuses on discussing the specific issues related to the patient him/herself and according to his/her clinical characteristics and situation.

Transferring the program to other contexts would require adjustments mainly related to cultural issues.

URL: n/a

Challenge addressed by the good practice

  • End of life/critical care-related decisions compromised by patients’ lack of competence
  • Patients’ preferences not being respected
  • Paternalistic attitudes regarding health-related decision making processes
  • Not enough training in communication by physicians and nurses about Advance Care Planning Talking with patients and relatives about end of life issues is not included in ordinary clinical meetings

Key innovative elements of the good practice

The program has not yet been formally evaluated. Nonetheless, listening to participating patients, families, GPs and Community Nurses has helped us understand how invitations to reflect and discuss values and preferences regarding treatment and care have been of much use both for all of them who now seem to share a common view of what kind of options the patient would choose for him/her when time comes.

Interviews inviting to reflect and discuss have been somehow systematically introduced into some Community Care Teams’ (GP and Community Nurse) agendas, and approaches to chronic care.

Healthcare professionals working at secondary/tertiary levels (mainly hospitals) now start to be familiar with the program and benefit from accessing the information regarding preferences accessible through the electronic health record.

Full Scirocco information on the good practice

SciroccoGP-Basque-3-Advance-Care-Planning-in-an-Integrated-Organisation.pdf [PDF]

Publications and reports on the good practice

Agreed evidence. Evidence is based on an agreed established monitoring system/process before and after implementation of the Good Practice.

Emanuel EJ, Emanuel LL. The promise of a good death. Lancet 1998; 351 Suppl 2:SII21-SII29. – Peter A.Singer MMF, Gerald Robertson LL, David J.Roy SPD. Bioethics for clinicians: 6. Advance care planning. Canadian Medical Association Journal 1996; 155:1689-1692. – Emanuel L. Appropriate end inappropriate use of advance directives. Journal of Medical Ethics 2001; 5(4):357-359. – Martin D.K, Emanuel LL, Singer P. Planning for the end of life. Lancet 2000; 356:1672-1676. – Emanuel LL, von Gunten CF, Ferris FD. Advance care planning. Arch Fam Med 2000; 9(10):1181-1187. – June Leland. Advance directives and establishing the goals of care. Primary care: clinics in office practice. 2001: 349-363. – Kolarik RC, Arnold RM, Fischer GS, Tulsky JA. Objectives for advance care planning. J Palliat Med 2002; 5(5):697-704. – Hahn ME. Advance Directives and Patient-Physician Communication. JAMA 2003;289:96.   – Curtis JR. Communicating with patients and their families about advance care planning and end-  of-life care. Respir Care 2000;45:1385-94.

Contact point: Iñaki Saralegui Reta; 

Back to top