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Advance Care Planning in FNW: GP collaboration improves dignity and quality of life for patients

Advance care planning conversations are key to ensuring that patients receive end-of-life care that aligns with their needs and beliefs. Recognizing this, Fraser Northwest division has been working with Fraser Health for the past four years to implement an effective and reliable method of transferring this information between doctors’ offices and facilities.  

The division’s work with the health authority led to the 2016 implementation of a fax system through which GPs can fax Medical Orders for Scope of Treatment (MOST) forms. The forms are then uploaded to MediTech and are available at all Fraser Health hospitals. Evaluation results show that approximately 400 MOST forms were faxed between October 2016 and March 2017, 85 of which were faxed by members of the Fraser Northwest division—including Dr John Yap. 

"I have a lot of complex elderly patients,” says Dr Yap. “When I review their medical problems one of the key goals is to determine a substitute decision maker for the patient. The next element is to initiate the advance care plan conversation.” That initial conversation is the hardest, according to Dr Yap. After that, he says, “the plan is reviewed annually, and the next iteration is always easier to do than the previous.”

To support physicians in leading advance care planning (ACP) conversations and completing MOST forms, Fraser Health developed the Advance Care Planning Framework. The framework details five different stages in a patient’s disease journey and the corresponding ACP conversations that should occur with each, starting as early as possible—in fact, while patients are still healthy. As the patient’s wishes are updated at each stage, an updated MOST statement is created and reviewed for goal concordance, family satisfaction, and quality improvement before being uploaded to MediTech. 

ER physician Dr Martha Koehn, a member of the Advance Care Planning committee, stresses the importance of supporting family physicians to have these conversations. “As an ER physician, it is very apparent when patients have had ACP discussions with their primary care providers in the community—it completely changes a patient’s experience when faced with a medical crisis.” According to Dr Koehn, the ACP process and the MOST form system ensure patients and their families are less burdened by decision making, and are more accepting of outcomes in the ER. “This allows me to treat them in a way that promotes dignity and quality of life,” she says.

The system of communicating patients’ ACP wishes by uploading MOST forms to MediTech is already showing a positive impact on patient care. A family member of a patient in the Fraser Northwest region provided input on how the MOST system changed their father’s care experience. “Three years ago,” said the family member, “my dad ended up in emergency and was unable to communicate due to complications with one of his medications.  I still remember the panic I had when the emergency doctor came and asked if I knew what my father's wishes were.”  

Forced to make a decision, the family told caregivers to do everything they could to keep their father alive. They were too distressed to consider what their father really would have wanted, and they admit, “It would have been much easier to have the ER doctor tell me what my father and his family doctor had discussed and to confirm that with me.”

Following that scare, the patient used the My Voice document to detail the his wishes for no extraordinary measures to be taken to prolong his life. However, the family soon learned that additional steps were needed to communicate the information to facilities. “Dad was discharged and readmitted three times after surgery within a week due to complications. Each time he came back to the hospital, the new physicians would then attempt to have ‘the discussion’ with us.  Each time was complicated with emotion and a level of discomfort from the physician who was not familiar with dad or his full history.” 

The system of uploading MOST forms to MediTech has solved the communication issue experienced by the patient and his family. “To know that my dad can have the discussion with his family doctor about his wishes and plans, and then know that this will be known at the hospitals in our region is a huge relief,” said the family member.

More information about the Fraser Northwest division’s advance care planning work is available on the division’s site. To view the Fraser Health Advance Care Planning Framework, click here, and to access advance care planning tools and resources from Fraser Health, click here.

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