The conversation for advanced care planning should begin before the onset of an illness. As clinicians we should be having these conversations with our patients early on so they may begin to plan for the future. It is important that we all communicate our wishes to loved ones, appoint a healthcare power of attorney and address financial issues such as wills and paying for long-term care.

Not only is it important for healthcare clinicians to have these conversations with patients, it is equally important for patients to have these conversations with their family or loved ones. These conversations are not easy to have, as many people would prefer not to think about serious illness, death and dying. The palliative care team often is an integral part of advanced care planning. Here are some tips that the palliative care team and healthcare clinicians may offer patients to help them talk with their family or a loved one about advanced care planning:

• Share what motivated you to start thinking of advanced care planning
• Discuss your views on religion and spirituality and how this impacts your view on death and dying
• Discuss how you feel about the dying process
• Address the level of importance in regards to living independently, living at home and if you want to die at home.

Culture, religious and spiritual beliefs also should be taken into consideration with advanced care planning.

Advance Directives

An advance directive (often called living will) indicates a person's wishes as it relates to medical treatment at the end of life. An individual creates this plan with written instructions. It is a set of instructions that a person wants medical professionals to follow, especially when the patient has lost the ability to communicate.

There are three kinds of advance directives:

1. Designating a healthcare representative or proxy. Patients may designate a person (a proxy) they trust and give that person the legal authority to make decisions for them if they are unable to make decisions for themselves. This chosen healthcare representative or proxy is the patient's substitute and takes part in discussions with the patient's physician and others responsible for their care.
2. Instruction Directives (commonly referred to as a Living Will). This is another way to have patients' wishes spelled out ahead of time relating to medical treatment. It provides those responsible for the patient's care with a statement of medical treatment preferences. It indicates medical treatments the patient wishes to accept or refuse and the circumstances in which the patient wants his or her wishes implemented. These instructions will serve as a guide to those responsible for the patient's care.
3. Combined Directives. This is a combination of designating a healthcare representative/proxy and having written instruction directives (living will). This will be a combined document where patients select a healthcare representative/proxy and provide him/her with a statement of their medical treatment preferences.

Healthcare clinicians should speak to their patients about completing an advance directive. Patients may need help from the healthcare or palliative care team in clarifying treatments and discussing options. It is recommended that the healthcare clinician obtain a copy of the patient's living will and provide a copy to at least one family member or healthcare proxy.

Why have an Advance Directive?

The importance of an advance directive is to be sure that one's wishes and concerns are documented. This legal document provides healthcare professionals with a patient's wishes for treatment, and it also assists family and loved ones in making difficult decisions on the patient's behalf. A clearly written directive helps prevent disagreements among those close to the patient and alleviates the burden of decision making for family and healthcare providers.

Designating a Healthcare Representative/Proxy

The persons chosen as healthcare representatives have the legal right to accept or refuse medical treatment on the patient's behalf. They represent and assure that the wishes relating to medical treatment are carried out. The healthcare clinician should advise the patient that the healthcare representative should be familiar with the patient's feelings about different types of medical treatment and the conditions under which the patient would choose to accept or refuse specific treatment.

Healthcare representatives must have a clear understanding of their responsibility to implement the patient's wishes even if they vary from their own. When having this conversation with your patient, encourage the patient to consider selecting someone whose judgment the patient trusts and has confidence in. People who may be considered to be one's healthcare representative include:

• A member of the patient's family or a close friend
• The patient's spiritual advisor, priest, rabbi or minister
• A trusted healthcare provider, however this cannot be the patient's attending physician as he/she cannot act as the patient's physician and healthcare representative at the same time.