Advance Care Planning in the Context of Metastatic Non-Small Cell Lung Cancer

QUESTION

This case study is adapted from Ben’s s story, who you’ll be familiar with from workshops you’ve attended: Ben is a 65-year-old, retired gentleman who lives with his supportive wife Jan. They have two adult children Jason and Rose. Ben was diagnosed with non-small cell lung cancer three years ago, and was treated with surgery, chemotherapy, and radiotherapy. Up until recently Ben had been fit and well, with scans showing no recurrence of the cancer. A month ago, Ben developed a cough and chest pain, and after seeing his doctor was referred for diagnostic imaging. Unfortunately, those investigations revealed a recurrence of Ben’s lung cancer, which has now metastasised. Please watch the conversation between Ben and his doctor here: https://www.youtube.com/watch?v=KPafo1s5N9A Ben has been well supported by Jan since receiving this news, however Jan has found Ben’s care increasingly difficult to manage. As such, Ben is transferred to an aged care facility for respite care. During Ben’s stay, Ben discusses his concerns about dying with Jen, a care worker at the facility. Please watch the conversation here: https://www.youtube.com/watch?v=bza_OM_NSC4 You are required to write a case -based essay that answers the questions listed below. Although you will need to understand the illness trajectory of metastatic non-small cell lung cancer, you are not required to discuss the specific pathophysiology of lung cancer; the focus of this essay is to explore the role of advance care planning in the context of Ben’s chronic illness progression as well as other relevant legislation pertinent to a person with a chronic illness. Some Victorian Acts to consider are: • The Medical Treatment Planning and Decisions Act 2016 (Vic.) which was last updated on 24/5/23 • The Guardianship and Administration Act 2019 (Vic.) which was last updated on 24/5/23 • The Powers of Attorney Act 2014 (Vic.) which was last updated on 26/4/21 (https://www.legislation.vic.gov.au/ ) Question One FIND the differences between the next of kin, a medical treatment decision maker, a support person, a power of attorney, and a guardian in relation to Ben? Please give examples of each describing their legal role involved in Ben’s care. Which one/s would be the most appropriate for Ben to have in his current condition? Why? Question Two Define advance care planning and discuss the possible benefits of advance care planning for both Ben and Jan. Question Three At what point during Ben’s illness trajectory might a conversation on advanced care planning be initiated with Ben? There may be differing opinions on this within the literature, please describe these giving examples as to why the opinions differ. Question Four When would an advance care directive be reviewed? Who can activate it and when?

ANSWER

Advance Care Planning in the Context of Metastatic Non-Small Cell Lung Cancer

Advance care planning (ACP) plays a pivotal role in providing comprehensive care to individuals with chronic and life-limiting illnesses. This case-based essay explores the role of ACP in the context of Ben, a 65-year-old man diagnosed with metastatic non-small cell lung cancer. It delves into the legal roles of different stakeholders, the benefits of ACP, the appropriate timing for initiating ACP conversations, and the review process for an advance care directive (ACD).

Question One: Legal Roles of Stakeholders

In Ben’s situation, several legal roles come into play:

Next of Kin: The next of kin holds no legal authority to make medical decisions on behalf of a patient. They are generally consulted for input, but their decisions are not binding.

Medical Treatment Decision Maker (MTDM): The MTDM is appointed under the Medical Treatment Planning and Decisions Act 2016 (Vic.) and has the legal authority to make medical decisions when the patient loses decision-making capacity. Ben’s wife, Jan, is likely his MTDM due to their close relationship and support.

Support Person: A support person assists the patient in making decisions, but their role is not legally binding. Jan, as Ben’s wife, can also fulfill this role.

Power of Attorney (POA): A POA has legal authority to make financial and legal decisions on the patient’s behalf. Ben may have appointed one of his adult children, Jason or Rose, as his POA.

Guardian: A guardian is appointed under the Guardianship and Administration Act 2019 (Vic.) to make personal and lifestyle decisions for individuals who cannot make decisions themselves. This role is less relevant in Ben’s case as he is still capable of making decisions.

In Ben’s current condition, having a designated MTDM is essential. Jan’s close relationship with Ben and understanding of his preferences make her the most appropriate MTDM.

Question Two: Benefits of Advance Care Planning

Advance care planning involves discussing and documenting a person’s healthcare preferences and values. For Ben and Jan, ACP provides the following benefits:

Autonomy:ACP allows Ben to express his preferences for medical interventions and end-of-life care, ensuring his voice is heard even if he becomes incapacitated.
Reduced Burden: ACP relieves Jan from making difficult decisions on Ben’s behalf during moments of distress, ensuring his wishes are respected.
Clarity: ACP eliminates confusion among family members and healthcare providers about Ben’s preferences, leading to more informed decision-making.
Improved Quality of Care;ACP promotes care that aligns with Ben’s values, ensuring he receives care that is consistent with his goals.

Question Three: Timing of ACP Conversations

ACP conversations can vary based on individual preferences and disease trajectories. Initiating ACP discussions with Ben can be approached in various stages of his illness:

At Diagnosis: Discussing ACP early allows Ben to consider his values and preferences while still coherent.
Upon Disease Progression: As Ben’s condition deteriorates, revisiting ACP helps ensure his preferences remain aligned with his evolving circumstances.
Before Invasive Interventions: ACP conversations can take place before procedures or treatments that may lead to increased risks or reduced quality of life.

Question Four: Reviewing Advance Care Directives

ACDs should be reviewed regularly and when there are significant changes in a person’s health or preferences. Ben’s ACD should be revisited:

Annually: To ensure his preferences are up-to-date and reflective of his current state.
Upon Disease Progression:As his health changes, ACDs should be reviewed to align with his current condition.
When Major Medical Interventions are Needed: ACDs should be reconsidered when major decisions or interventions are required.

Reviewing ACDs can be initiated by the patient, family members, medical providers, or the MTDM. As Ben’s condition changes, Jan or Ben’s medical team can activate the review process to ensure his preferences are respected.

In conclusion, advance care planning plays a crucial role in guiding care decisions for individuals with chronic illnesses like metastatic non-small cell lung cancer. By involving various stakeholders, defining legal roles, and discussing preferences, ACP empowers patients like Ben to receive care that aligns with their values and goals, while relieving their loved ones of the burden of decision-making during difficult times.