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Critically analyse policy pertaining to advanced care directives and critique their implementation in practice. Essay Example

  • Category:
    Nursing
  • Document type:
    Essay
  • Level:
    Masters
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    2914

IMPLEMENTATION OF ADVANCED CARE DIRECTIVES 11

Critical Analysis of Policy Pertaining to Advanced Care Directives and a Critique of their Implementation in Practice

Palliative Care Policies Implementation in respect to Advanced Care Directives

The introduction of palliative care in the Australian Health care system was aimed at improving the quality of life among patients and their families faced with chronic illnesses. Palliative Care is defined as specialist care that is provided to all people who are living, and dying from terminal illnesses, and whereby the quality of life is the primary goal (PCA, 2014). Its major goal targets provision of pain and symptom relief coupled with spiritual and psychosocial support. On the same note, Advanced Care directives (ACDs) are crucial in provision of means for people to have the opportunity to plan prior for situations where their decision making may be required but they would not be in a position to decide (AHMAC, 2011). These are life management documents completed by individuals at home, community, institutional and aged care facilities, or even hospitals with the main aim of ensuring quality of life during critical stages. In regard to palliative care approaches, they are linked to palliative care and utilised in primary care services by medics to raise the quality of life in palliative facilities. Thus, this essay evaluates the aspect of palliative care directives in Australia and critically how it has been influenced by various positions in the society.

Advanced Care Planning (ACP) is a process that prepares likely scenarios close to the extreme of life incorporating assessment of and conversation touching on how individuals perceive their medical history, as well as condition, preferences, values and personal and family resources (Detering, Hancock, Reade, et al., 2010). On the other hand Advanced Care Directive (ACD) refers to a document that expounds on the future preferences of an individual pertaining to medical treatment in anticipation of a moment in case one is not in apposition to describe their preferences due to illness or injury (Alfonso, 2009). This is also termed as ‘living will.’ Silvestre, Fullam, Parslow, et al. (2012) indicates that application of palliative approach in looking after critically ill should not be delayed till the latter stages of an illness. Planning and implementation of effective care ought to take centre stage before any given person deteriorates to chronic conditions or else state of not making any effective decisions. The introduction of specialist palliative care creates an approach that is adopted by primary care providers bringing up elevated standards of experience for clients and their families (Alfonso, 2009).

The demand of palliative care in Australia has been on the rise and it is expected to grow with time (Goodwin, Dixon, Anderson and Wodchis, 2014). This prompted the introduction of policies and directives aimed at enhancing and making available advanced care, as well as affordable and accessible. The Government of Australia ensures support for people living with life threatening illnesses via the National Palliative Care Programme (PCA, 2014). Further, affordable medications which are useful in management of palliative care are provided under the Pharmaceutical Benefits Scheme (PBS). At the national level, Palliative Care Australia is the peak body for palliative care with every individual state and territory having local branches to tackle the programme. Nevertheless, amid the efforts and interventions made countrywide, the policy directives are normally affected by changes in the political, legal, ethical and philosophical positions (Crisp, Taylor, Douglas, and Rebeiro, 2012).

To ensure quality palliative care for all chronically ill people, effective advance care planning (ACP) calls for a number of key processes to be undertaken and revised as necessary via continuing practitioner-patient negotiations (Silvestre, et al., 2012). The processes incorporate of: considerations of options and expressions of values; communication, as well as preferences documentation; identifying surrogate decision maker where possible to make decisions in respect to treatment when the said preferences and decisions cannot be made by the patient (AHMAC, 2011); and finally to ensure the documentation process availability in respect to clinical staff in various healthcare facilities like when patients are transferred from an aged care facility to hospital wards (Stjernsward, Foley and Ferris, 2008). Not all patients in palliative care or with life limiting illnesses require the attention of specialist care. In most cases, majority of individuals only visit their specialist practitioner as per their palliative care needs once in a while and if there is any particular need. Care management planning therefore calls for policy making and implementation taking into consideration all aspects of palliative care touching on the critically ill (Badger, Clifford, Hewison, et al., 2011).

There has been a global shift pertaining to policy in respect to approaches to health care resulting to movement towards greater involvement of persons within the management of their individual health (Detering, et al., 2010). The given shift has specific importance in respect to healthcare settings which are challenged to meet the needs of an ageing population as well as the chronically ill patients. The aspect of self-management stands for individuals getting actively involved in managing their own illness and not necessarily receiving information from health practitioners who specialises in the areas of interest (Hickman, Nelson, Moss, et al., 2011). This social aspect of self-management brings up support for the same standing for the role of clinicians to play assessing and building knowledge, skill and confidence to effectively manage their own health care and wellbeing, as well as treatment (Stjernsward, Foley, and Ferris, 2008). This evaluates the effective way of the healthcare professional’s participation and operationalization of self-management policies to support patients having terminal illnesses.

There exists a plethora of findings describing the aspect of self-management while at the same time recommending enhanced involvement of patients in their own care (Goodwin, et al., 2014). Nevertheless, there is less understanding of the experiences within health practitioners who implement strategies necessary to support these patients. The Australian context is characterised with the National Health Agenda of 2009 which redesigned primary health care (PHC) to meet given objectives which incorporate a greater focus on achieving ‘Patient-centred and supportive to the health literacy, self-management, as well as individual presence (PCA, 2014). Amid the fact that self-management has been discussed earlier in this context as essential, with regard to palliative care, policy interaction with political, legal and philosophical issues have a direct stake in the overall outcome of the care. In spite of international policies initiatives, the proliferation of competing and overlapping approaches crucial to support self-management and effectiveness of case management, have brought up ambiguity in both policy and practice (Crisp, et al., 2012). This is in regards to how best the two strategic measures of management of chronic cases influence the overall improvement of end of life quality.

The delivery of standardised care by inter-professional staff ensures improvement of continuous care. The roles and responsibilities of every strategic measure introduced in palliative care ensure overall growth in prolonging life and improving its quality at the end of life stages (AHMAC, 2011). On the same note, they are charged with ensuring smooth transitions of patients from one form of care to another. For effective and cohesive implementation of the set policies with respect to inter-professional staff, shared protocols based on evidence are highly important (Goodwin, et al., 2014). Further, they are essential and help in the standardization of care in all facilities thus, improving quality of care. The integration of such form of policy formulation and implementation is entrenched in the aspect of integrated health systems which depends upon developed, and efficient monitoring systems which incorporate indicators to evaluate the outcome at various levels (Badger, et al., 2011).

Case management refers to the coordination of services for individuals having terminal illnesses through assigning every person a case manager. According to the Commonwealth Fund Survey (2012) cited in Goodwin et al. (2014), the percentage of practices in Australia using case managers account for 59%. Amid the fact there are extensive information pertaining to case management, there lacks quality work backed with consistent evidence for the effectiveness of case management of people having terminal illnesses (Stjernsward, Foley and Ferris, 2008). The incorporation of organisation and services in the realisation of integrated health system via establishing contractual relationships or networks is vital in enhancing effectiveness of case management to all patients. Case management models like HealthOne established in Western Sydney was effective in respect to better care planning and case management of older person shaving complex health needs supporting more appropriate links to the care providers and thereby lessening the number of hospital admissions (Goodwin, et al., 2014). Nevertheless, there is need for creation and development of governance structures to ensure coordination is enhanced. This is respect to ensuring representation from diverse sectors which understand the needs necessary in the healthcare alongside its continuum incorporating both the medical practitioners and the society.

Directives or interventions on how to determine patients that can or not be involved in decision making process on the issues pertaining to their health are lacking (Silvestre, et al., 2012). Nevertheless, through interactions, it is evident that improvement of people’s knowledge in respect to their condition is enhanced by care management. This is achieved through provision of clear accessible information that can be utilised and understood by any lay person or educator, as well as group educational sessions. According to Badger, et al. (2011), with continued awareness, patients are able to gain insights to even learn more on their own. It is evident that self-management education programmes are useful in helping individuals manage their prevailing health conditions. These interventions are critical and crucial due to the fact that they tend to bring down the effects of symptoms, as well as reduce visits to primary and secondary care (v 2009). Further, self-monitoring is also another aspect that is promoted with self-management. There is crucial evidence that self-monitoring enhances clinical outcomes for individuals with specific conditions (Badger, et al., 2011). With technology; monitoring through computers and telecommunication is viable and can be associated with clinical outcome improvement in respect to given conditions.

The implementation of redesigning within the healthcare delivery models has been evident in Australia (AHMAC, 2011). The health departments embraced the issue of reforms supporting case management and self-management for patients with chronic illnesses. The clinicians have been charged with the responsibility of understanding and implementation of the policy directives to be able to embrace new strategies in the care services (PCA, 2014). However, there are little impacts made in respect to creating greater awareness pertaining to individual in need of palliative care and the necessity to indulge in advanced care planning initiatives. Processes and strategies were put in place with the main aim of ensuring implementation that is in alignment, as well as supports the guiding principles within the policy directives (Crisp, et al., 2012). The major emphasis behind this comes into focus with respect to services location and information systems failure to which targeted outcomes would be missed. According to Silvestre, et al. (2012), utilisation of a continuum of strategies backed from macro to the micro spanning funding, administration, service delivery, organisational and clinical areas is imperative. Further, the integration of strategies targeting effective communication and access; culture, values and teamwork; as well as commitments and incentives are crucial in the delivery of integrated care.

The social, economic and political contexts have their effects upon care delivery, and their effects to legal aspects, funding streams, as well as broader integrating mechanisms due to the fact that they constitute crucial determinants of success in respect to integrated service delivery models (Goodwin, et al., 2014). To ensure proactive management in the functional decline of older persons during hospital admissions, there is need for critical assessment. Review of such screening and assessment processes is paramount with respect to ensuring improvement of palliative care (Detering, et al., 2010). Embracing comprehensive assessment ensures a framework whereby all areas of potential risk are covered, incorporating areas that are neglected like depression and delirium in patients. With integrated care, it is expected that short durations in acute care settings would result to prompt identification of risks in order to ensure that safe and effective channels are developed to manage the needs of the person in need of care (Badger, et al., 2011). The approaches devised should underpin the screening and assessment process in order for care providers to comprehend preferences and needs of the recipient; the needs of the family of an aged person or carers; and understand an aged individual’s status prior to admission (Crisp, et al., 2012).

The philosophical nature of policy effects comes about in respect to interpretation, evaluation and comprehension of the set out strategies. This directly affects the overall implementation of the policies with respect to efforts and interventions made to realise the set out goals (Stjernsward, Foley and Ferris, 2008). The cultural diversity aspect pertaining to integrated palliative care services is crucial in assisting to ensure maintenance of comfort and dignity. The recipients of care are assured of care that looks into the cultural diversity across all integrated palliative care services assisting in ensuring all clients are comfortable by getting appropriate interventions in the care (Goodwin, et al., 2014). This is through respect and valuing every individual’s uniqueness. Communication issues are addressed critically by the palliative teams to ensure provision of accurate and appropriate physical care, as well as come up with meaningful relationship with care recipients and their families (Stjernsward, Foley and Ferris, 2008). Cultural aspects create conflicts in respect to clients and caregivers having no sense of harmony and lacking understanding of each other. Thus, understanding the cultural and religious factors is crucial among palliative care teams in order to influence the manner in which clients receive the care together with their families (Hickman, et al., 2011). The aspect of culture is also vital in respect to addressing issues of death and dying and any decision making processes be guided by the same beliefs. These two issues are sensitive and significant events in all societies. Thus, it is imperative that palliative care policies have directives touching on the cultural aspects to be incorporated in the care services (Stjernsward, Foley and Ferris, 2008). The major context of this regards to respect and support of customs, beliefs, practices and rituals that can lead to comfort and meaning to care of the clients and their families.

On critically assessing the essence of palliative care, life improvement entails appreciating being alive irrespective of the pains or symptoms being endured. Looking at the Model of Care for the Older Person, its main focus is to promote independence, wellbeing and quality of life among the critically ill and aged (Goodwin, et al., 2014). Mainly, its emphasis is on the prevention and enhancement of programs encouraging self-management of health conditions. The model has a core aspect of ensuring critical concentration on service delivery which is more cost-effective, extra-oriented to care needs necessary and less hospital settings centred (Silvestre, et al., 2012). Generally, with improved coordination and communication, the process is core to the approach of palliative care. The use of patient self-care interventions are critical undertakings with their involvement in decision making (Alfonso, 2009). Inclusion of individuals with chronic conditions within the decision making process is useful in the improvement of their satisfaction level. However, there are no clear indications of how effective this strategy can be utilised (Detering, et al., 2010).

In conclusion, it worth noting that palliative care is paramount in improving quality of life among people living with chronic illnesses. The aspect of advance care directives comes into focus within palliative care setting in respect to ensuring effective planning prior to deterioration of an individual’s health condition. Nevertheless, this is affected by various aspects in life triggering conflicts and debates aimed at ensuring effective palliative care are achieved. The essay has evaluated a number of issues surrounding palliative care in the Australian context, as well as the policies and directives influence in palliative care.

References

Alfonso, H. (2009). The importance of living wills and advance directives. J Geront Nurs, 35: 42-45.

Australian Health Minister’s Advisory Council (AHMAC) (2011). A national framework for Advanced Care Directives: The clinical, technical and ethical principal committee of the Australian health Minister’s advisory council. AHMAC.

Badger, F., Clifford, C., Hewison, A., et al. (2011). An evaluation of the implementation of a programme to improve end-of-life care in nursing homes. Palliat Med. 23: 502-511.

Crisp, J., Taylor, C., Douglas, C. and Rebeiro, G. (2012). Porter and Perry’s fundamentals of nursing, 4th ed. Sydney: Mosby Elsevier.

Detering, K. M., Hancock, A. D., Reade, M. C., et al. (2010). The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ. 340: 1345.

Goodwin, N., Dixon, A., Anderson, G. and Wodchis, W. (2014). Providing integrated care for older people with complex needs: Lessons from seven international case studies. The London: Kings Fund.

Hickman, S. E., Nelson, C. A., Moss, A. H., et al. (2011). The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc, 59: 2091-2099.

Palliative Care Australia (PCA) (2014). Accessed May 16, 2014 from <http://www.palliativecare.org.au/>.

Silvestre, W., Fullam, R. S., Parslow, R. A., Lewis, V. J., Sjanta, R., Jackson, L., White, V. and Gilchrist, J. (2012). Quality of advance care planning policy and practice in residential aged care facilities in Australia. BMJ Support Palliat Care. doi:10.1136/bmjspcare-2012-000262.

Stjernsward, J., Foley, M. and Ferris, F. (2008). The public health strategy for palliative care. JPSM, 3(5): 486-493.