Ethics & law: advanced care planning 1

A 54-year-old lady comes to the GP seeking information on advanced care planning

Candidate Instructions 🧒

You are the FY1 working in GP.

Your next patient is a 54 year-old-lady, Mrs Annabelle O'Connor.

Mrs O'Connor was diagnosed relapsing-remitting multiple sclerosis 20 years ago. She has come in today wanting to know more about advanced care planning, as she is worried about her slowly deteriorating condition.

Please elicit a brief history, check her current understanding and answer her questions.

Station time: 10 minutes (3 minutes for history + 7 minutes for questions)


Station Material (ONLY OPEN WHEN PROMPTED)

There are no station materials for this station

Actor Instructions 🤒

Name: Mrs Annabelle O'Connor
DOB: DD/MM/YYYY
Age: 54

Agenda:

  • You have come to terms with your diagnosis over the years, you have been reading about the topic but find it all quite confusing, you are keen to listen to what the doctor has to say and suggest
  • You feel lucky to have this long whilst still being relatively healthy

ICE:

  • I: You believe it is necessary for you to tackle this topic sooner than later
  • C: You are concerned that your family will suffer the consequences if you don't put all of these affairs in order
  • E: You expect to know more about this topic and to be given time to digest the information in order to make the best decision

PMHx:

  • Relapsing-remitting multiple sclerosis diagnosis 20 years ago
  • Diagnosed after feeling 'odd sensations' in legs
  • Diagnosed with brain MRI
  • Previous multiple optic neuritis -- vision permanently deteriorated
  • Urinary frequency present at the moment -- embarrassed by this
  • No other significant medical history
  • No family history of multiple sclerosis
  • Interferon treatment
  • Methylprednisolone -- acute flares
  • Natalizumab -- trialled (poor result)
  • Teriflunomide -- trialled (poor result)
  • 1 daughter, 2 sons
  • Husband is primary carer
  • Occupation was teacher, stopped working 6 years ago for health reasons
  • Normally manage alone with activities of daily living -- during flares need assistance e.g. toileting, travel, shopping
  • Prognosis is fatal within 10-15 years

Understanding:

  • Read about advanced decision to refuse treatment, lasting power of attorney and advance statements
  • All sound very similar
  • Do not understand the differences

Question 1: What is an advanced decision to refuse treatment?

Question 2: What is lasting power of attorney?

Question 3: What are advance statements?

Question 4: What happens to me if I can no longer make decisions and have not made any form of advanced care plans?

Question 5: What happens if I make an advanced decision to refuse treatment and nominate a lasting power of attorney?

Mark Scheme ✍️

Introduction

Washes hands
Full name and role
Checks patient's name and DOB
Explains purpose of consultation
Enquires about ideas, concerns and expectations
all-markschemes.introduction

Past medical history

Type of multiple sclerosis
Timeframe of disease
Signs and symptoms
Other significant medical history
Drug history
Family history of multiple sclerosis
Social history
Caring assistance
Independence with activities of daily living
Prognosis
history-markschemes.past-medical-history

What

Current understanding

Establish current understanding of advanced care planning
explanation-markscheme.what

Questions

What is an advanced decision to refuse treatment?

Instructions regarding REFUSAL of medical treatment ONLY
Made by person over 18y/o
IF 'valid and applicable' ADRT must be followed (legally binding)
Valid at time of writing - capacity/non-coerced/adequately informed
MUST be written, signed and witnessed
Circumstances specific to patient and situation
Applies once patient no longer has capacity
Commonly used regarding life-saving/sustaining treatment e.g. CPR, fluids, parenteral nutrition
all-markschemes.questions

What is lasting power of attorney?

Patient appoints person/donee to make decisions on their behalf
Applies once patient no longer has capacity
Powers are specific - health/welfare/property and financial affairs
Circumstances specific to patient and situation
Instructions regarding REFUSAL of medical treatment ONLY
Made by person over 18y/o
all-markschemes.questions

What are advance statements?

NOT legally binding
MUST be considered when assessing best interest
Patient wishes and preferences regarding treatment
all-markschemes.questions

What happens to me if I can no longer make decisions and have not made any form of advanced care plans?

Decisions made in patient's best interest
No ADRT, LPA or deputy of court, patient's doctor (consultant) becomes decision maker
all-markschemes.questions

What happens if I make an advanced decision to refuse treatment and nominate a lasting power of attorney?

Most recently made decision takes priority
IF lasting power of attorney has power to make decisions in question
all-markschemes.questions

Conclusion

Summarises + closes consultation appropriately
Patient questions
Offer additional resources (online or leaflet)
Offers further consultations
Thanks patient
all-markschemes.conclusion

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