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Peer Reviewed Article

Evidence in Action

Advanced Care Planning:


How does current practice compare with best practice?
Elizabeth van der Spek BN, JBI Clinical Fellow

An audit of 71 resident notes in a 73-bed residential aged care facility

Abstract
Advanced care planning (ACP) is a means of conveying ones wishes regarding medical treatment while still having the cognitive capacity to ensure ones preferences are known in the event that the ability to make decisions and/or convey them is later lost. As such, ACP can maintain an individuals autonomy. In the Residential Aged Care Facility (RACF) the use of ACP has become part of standard admission documentation, allowing residents and families to discuss and plan for possible future care needs. An audit of ACP highlighted that although every resident had an ACP, they were not always completed correctly, had conflicting information, or were incomplete. In addition, some nurses reported anxiety or discomfort when approaching residents and relatives to discuss end-of-life care issues. The project was conducted to determine what was considered to be best practice, and whether the RACF met best practice criteria. This would determine what changes would need to be made to improve completion of ACP, to provide residents and relatives opportunities to discuss ACP, and to increase nurses confidence and skills in the area of ACP. Addressing these areas would thereby improve outcomes for residents, relatives, and staff. The project was undertaken using JBI Practical Application of Clinical Evidence System (PACES) and Getting Research Into Practice (GRIP) online software. Using PACES, current best practice criteria were identified, and an initial audit was conducted to determine the RACFs performance, relative to best practice. GRIP was then used to develop strategies to change and improve current practice. Strategies were implemented, which included revision of documentation, education for residents and relatives, and also education for nurses. Following the GRIP phase of the project, a post-implementation audit was conducted. Although the project was conducted over a relatively short time frame, results of this audit indicated that practice around ACP had improved.
Key words: Advanced Care Planning, End-of-Life Wishes, Nurs-

ing, Resident Autonomy, Residential Aged Care

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35 Evidence in Action

Acknowledgements

Australian Government Department of Health and Ageing for financial support Corumbene Nursing Home: Board of Management and Mr. Andrew Power (CEO) for their financial support, Residents and Relatives for their assistance in the project, the project team (Cecily Verrier DOC, and Heather Mc Ewing QPN), and also the nurses for their interest, support, and encouragement. Joanna Briggs Institute (JBI), Adelaide JBI Jan 2008 cohort of Clinical Fellows, Craig Lockwood, Amanda OConnell, and Zuben Florence. Ruth Haynes, Residential Aged Care Liaison Team, Royal Hobart Hospital and Julie Dunbabbin GP South Tasmanian Division of General Practice for providing information, pamphlets, and education sessions.

Having ones family know, or knowing a loved ones wishes for ACP can bring comfort and relief.9 Without this, family members have to make difficult decisions concerning treatment, usually at a highly stressful and emotional time, sometimes resulting in ongoing guilt and conflict.8 Further difficulties arise where there may be differing opinions about the best course of action, or when all concerned parties may not be present.10 While death and dying may be difficult to discuss, it is more likely that the individual will receive treatment which is acceptable to them if they have made their wishes known.11 Advanced care planning provides individuals with an opportunity to discuss, plan, and document preferences for healthcare interventions.15 This process should ideally involve families and/or significant others so that they have an awareness and understanding of the individuals wishes.16 An advanced care plan completed by a competent individual enables them to extend their autonomy in decision making even when they are no longer able to make or convey decisions for themselves.5,17 It identifies an individuals expectations and preferences relating to end-of-life care and informs families and medical professionals of preferences for treatment when an individual is no longer able to make or convey those decisions themselves.5,13 An ACP may nominate a person or persons to make decisions on behalf of the individual as in a Medical Enduring Power of Attorney (MEPoA) or Enduring Guardianship.12,14 Given that the adoption of ACP has been low, it is evident that the advantages of completing an ACP while competent to do so, is poorly understood.2,18 Despite the apparent lack of interest in ACP by the general population,2 RACFs encourage residents to complete an ACP, usually on admission.14,19 To provide optimal care at the end stage of a residents life, nurses need to have access to accurate documented information regarding the residents expectations and wishes.20 Given that most residents will die within 12 months of admission and some may die soon after admission, it seems timely to at least begin discussions about ACP as early as possible.21 End-of-Life Wishes or ACP have been part of the standard documentation at the

Background
Planning for the end of ones life may not be at the forefront of many peoples minds, perhaps most believing that this is the domain of those requiring palliative care. Yet death and dying are inevitable, and most people would have ideas about what quality of life they would or would not accept, and what treatments they would or would not agree to were they able to convey their wishes.1,2 Residential Aged Care Facilities promote Ageing in Place, where the resident has security of tenure until the end of life. Therefore, the residents room is seen as their home, where many residents prefer to be allowed to die comfortably and peacefully, cared for by people they know. Technology is such that life can be maintained artificially and almost indefinitely. Many people however, would not consider enduring the burdens of this to be classified as living.3 Interventions and treatments which only serve to prolong the dying process could be seen to be inappropriate.2 Yet if the individual is not able to convey their wishes and there is no Advanced Care Plan (ACP) or family member to speak for them, unwanted treatments and interventions may occur. Traditionally, people tended to accept a paternalistic approach to healthcare and those who still do may prefer not to discuss or complete an ACP.4 However, many individuals now expect to have autonomy and choice relating to their healthcare needs.5,6 Through planning for possible future medical events, individuals can maintain their autonomy, even when they are unable to communicate their wishes or make decisions themselves, and society now expects that these wishes will be respected.7,8

Nursing Home for many years. However, the information captured by these forms varied over time. In 2007, a routine Continuous Improvement audit of ACP identified that while the policy was all residents have an ACP, some did not and others were incomplete or incorrectly completed. In addition, the RACF generally do not adopt current best practice criteria.22 It was therefore timely to review the RACFs practice in terms of what is considered to be current best practice. The identification of how our practice compares with best practice enabled this RACF to implement practice change, improve staff confidence and competence in this area, and improve outcomes for residents.

Audit question
Advanced Care Planning: does current practice at this residential aged care facility reflect best practice in relation to endof-life care?

Aims/objectives
To establish our facilitys current level of compliance with best practice in the area of ACP. To improve compliance in completion of forms. To ensure our practice in ACP is based on current evidence-based best practice standards. To provide opportunities for residents and families to discuss and plan for endof-life care. To increase confidence of staff in discussing end-of-life care. To improve outcomes for residents as their end-of-life care wishes will be documented.

Audit criteria
The project team utilized the JBI PACES and GRIP software for this project. The online audit tool (PACES) identified 6 best practice criteria for the topic of ACP. 1. There is documented evidence that the client has been involved in the advanced care planning. To achieve yes in this criteria the ACP must be signed by the resident or there was written acknowledgement on the care plan that this had been discussed with the resident; and the ACP was filed in the residents chart

36 Evidence in Action

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2. There is documented evidence that the clients family or significant others have had the opportunity to be involved in the advanced care planning. To achieve yes in this criteria the ACP must be signed by family or significant other, or there was documented acknowledgement that there had been discussions with family or significant other; and the ACP was filed in the residents chart 3. Staff who complete advanced care plans have received training in this area. To achieve yes in this criteria there must be documented evidence in the staff training records that the nurse had received training in ACP 4. Staff who implement advanced care plans have received regular education regarding end-of-life care issues. To achieve yes in this criteria there must be documented evidence in the staff training records that the nurse had received further training in ACP 5. There is documented evidence that the clients family or significant others have received education regarding changes that may occur in the end-oflife phase. To achieve a yes result for this criteria the family or significant other had been given some form of education, including attendance at a training session and/or an information pamphlet 6. There is evidence of ongoing assessment to ensure the advanced care plan addresses all the relevant issues as the clients state of health alters.

To achieve yes in this criteria there must be documented evidence that the ACP had been reviewed within the past 12 months; or there was documented evidence that the resident, family, or significant other had been given or sent the new ACP for completion

Setting and sample for the project


The RACF is located in a rural area of Tasmania. It is a community owned, standalone facility serving primarily the local community. This 73-bed residential aged care facility comprises fifteen low care, fifty-eight high care (including twelve dementia specific) and two respite beds. For the purpose of this project, seventy-one permanent resident files were audited. The two respite beds were excluded on the basis that the length of stay in respite was often very short, frequently only two weeks. In addition, all of the RACFs seventeen registered and enrolled nurses were included in the project.

tion, the current proforma was reviewed against best practice criteria to determine whether appropriate information was being collected. In Phase 3, interventions were implemented to address areas where best practice standards were not met. Phase 4 required a second audit using the same criteria as the first audit. This was undertaken to determine the effectiveness of the interventions. The findings were prepared for publication (Phase 5).

Results Audit 1
The table below (Table 2) highlights the results of the pre implementation audit and the post implementation audit. The initial audit of Criterion 1 demonstrated that of 71 files audited, all residents had an ACP. However, only 28 (39.4%) of the ACP were either signed by the resident or there was written acknowledgement that this had been discussed with the resident, and the ACP was filed in the residents chart. Similarly, the audit of criterion 2 demonstrated that of the 71 files audited, all had an ACP, but only 41 (57.72%) had documented evidence that the clients family or significant other had been involved in the ACP. Criterion 3 focused on nursing staff (registered and enrolled nurses) training. The training records of all nursing staff (n=17) were audited with an outcome highlighting that of the 17 nurses, 0 (0%) had received specific ACP training. It follows that Criterion 4 was not met, with 0 (0%) of the 17 nurses having received regular education in ACP. There was no formal opportunity to audit Criterion 5 as RACF records did not capture this information. Therefore, as there was no documented evidence of families or significant others having education regarding changes that occur during the

Method
An audit and feedback approach was adopted, using a process embedded in the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) program. PACES is an online audit based tool using evidence-based practice to determine appropriate audit criteria to meet best practice standards.23 Audit and feedback have been identified as an effective tool to implement practice change.24 This project was conducted in 5 phases. In Phases 1 and 2, JBI PACES was used to conduct an initial audit of ACP from all permanent resident notes (n = 71), and staff training records (n = 17). This identified current practice and nurse skills. In addi-

Table 1: Overview of Project Methods and Time Line


Jan 08 Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Identify practice area & audit criteria Baseline audit determine current practice Implementation of strategies to correct non-compliance Post-implementation audit Project report writing Feb 08 Mar 08 Apr 08 May 08 Jun 08

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37 Evidence in Action

Table 2. Pre and Post-implementation results in detail


Audit Criteria 1 2 3 4 5 6 There is documented evidence that the client has been involved in the advanced care planning There is documented evidence that the clients family or significant others have had the opportunity to be involved in the advanced care planning. Staff who complete advanced care plans have received training in this area. Staff who implement advanced care plans received regular education regarding end-of-life care issues There is documented evidence that the clients family or significant others have received education regarding changes that may occur in the end-of-life phase. There is evidence of ongoing assessment to ensure the advanced care plan addresses all relevant issues as the clients state of health alters N 71 71 17 17 71 71 Audit 1 #Y % 28 41 0 0 0 0 39.4 57.72 0 0 0 0 N 71 71 17 17 71 71 Audit 2 #Y 37 68 15 0 10 71 % 52.1 96.8 88.2 0 14.1 100

end-of-life phase, this criteria was not met. As such, a result of 0 (100%) of 71 files audited recorded a No response. Similarly, the ACP used did not capture information, which could provide evidence of ongoing assessment. Therefore, the pre implementation audit showed that 0 (0%) of 71 files audited had evidence of ongoing assessment to ensure the ACP addressed all relevant issues as the clients state of health altered.
Strategies for GRIP (getting research into practice)

nurses knowledge and confidence, and to develop enthusiasm for the project.
Criteria 1, 2, and 6

Strategies for Getting Research Into Practice (GRIP) focused mainly on communication with clinical staff (nurses), in both written and verbal form. As nurses are key stakeholders this project was undertaken in a collaborative manner. Nurses were engaged in the process and in implementing practice change. Therefore, regular communication of progress and ongoing encouragement would be crucial to the success of the project. Completing regular small audits of progress towards goals, with feedback to nurses has proven to be an effective strategy in maintaining momentum of practice change. The initial audit identified that the RACF did not meet best practice criteria. Therefore targeted strategies were developed for each criteria to ensure that practice could be improved to achieve optimal outcomes for residents, families, and significant others. In addition, it was evident that formal ACP training had not been offered to nurses. Education sessions were needed to improve

The current end-of-life wishes form was reviewed. It was evident that, unless the resident signed the form, there was no record that the resident had or could be involved in the ACP. Similarly, the form did not identify whether families had been involved in the planning. Clearly, the current form did not meet our needs and would have to be revised and amended. The Royal Hobart Hospital (RHH) Residential Aged Care Liaison (RACL) Team was used as a resource, as they were encouraging the use of Statement of Wishes forms when residents were transferred from RAC to acute care. This form was obtained, and parts of it were used to create a new End-of-Life Wishes document. Several drafts were developed and revised, and a form that met the Nursing Homes needs, the needs of the RHH, and also complied with JBI criteria for evidence-based best practice was created and adopted for use. A limitation of the project arose where nurses could not reach an agreement as to how frequently the form should be reviewed. This continues to be debated at the time of writing.
Criteria 3, 4, and 5

tives Committee was approached informally initially and then by letter detailing the project and requesting time at the next monthly meeting for an education session. Enthusiasm for the education session was promoted using posters and flyers around the Nursing Home, and a mailing of an invitation and pamphlets to all relatives/significant others. A member of the RHH RACL Team, and a staff member from GP South (Tasmanian Division of General Practice) hosted the education session and provided posters, pamphlets, and Enduring Guardianship forms, and the RACF provided ACP at the session. ACP training sessions for nurses were incorporated into a fully paid nurse-training day, as this strategy was most likely to achieve the best attendance. Again, the RHH RACL team member delivered the training along with written information for staff. Following the education sessions, the new End-of-Life Wishes form was sent out to all residents or relatives with a covering letter explaining the rationale for the new form. Residents and relatives were encouraged to discuss ACP with nursing staff, and nursing staff were encouraged to seek opportunities to discuss this area of care with residents and relatives.

The strategy to meet these criteria was to source a skilled educator to deliver training sessions for staff with separate sessions for residents and relatives or significant others. This would lend weight and significance to the project, which would result in improved outcomes. The RACFs Residents and Rela-

Results Audit 2
The post implementation audit (Audit 2) showed a marked improvement in compliance with best practice. Criterion 1 recorded 37 (52.1%) of 71 files were compliant with the criteria, while Criterion 2 recorded 68 (96.8%) of 71 files.

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Of the 17 nurses, 15 (88.2%) received training specifically directed towards ACP. Given the short timeline of the project, Criterion 4 has not been met as 0 (0%) of 17 nurses have received further education. This was due to the short-term nature of the project; however, regular education in ACP is now listed as a requirement in the annual staff training plan. Criterion 5 recorded 10 (14.1%) of 71 files had documented evidence that the clients family or significant other had received education regarding changes that may occur during the end-of-life phase. Given that every resident and/or their family or significant other have been given the new ACP and were encouraged to discuss and review their endof-life wishes, 71 (100%) of 71 files were deemed to be compliant in Criterion 6. Figure 1 below offers a comparison of the pre audit and post audit data.

Discussion
Prior to the commencement of this project, an audit of ACP was conducted as part of the RACFs Continuous Improvement policy. This audit showed that the use of ACP in the Nursing Home was high where the majority of residents had an ACP, although the literature states this is not necessarily the case in aged care.2 However, some residents ACP had not been completed, were incomplete, or were incorrectly completed, which did not meet best practice. Nursing staff then assisted residents and relatives to complete ACP.

When completing the ACP, staff encountered instances where the resident and their relative or significant other had opposing views and expectations around end-of-life care. It became evident that for some residents and relatives there had been little or no prior consideration or discussion in this area. In addition, it was evident that the information collected on the forms was sometimes incomplete or vague, with comments like wait and see when the time comes or whatever the doctor says. In addition, some staff members stated that they did not always feel comfortable discussing these aspects of care with the residents or their relative or significant other. It seemed timely to review the RACFs practice around ACP. Therefore, this area of practice was chosen for the Joanna Briggs Institute Evidence-Based Clinical Fellowship Program, as the online PACES and GRIP programs would be ideal tools for changing current practice (Phase 1). The project team began Phase 2 by revising the currently used form. For this purpose, forms used by other organizations were collected and the relevant sections of them were incorporated in a new ACP. This was further revised to meet the RACFs needs and meet best practice criteria. The new ACP was introduced as part of the initial documentation on admission. However, as a result of this project it was identified that perhaps a better practice would be to discuss and provide informa-

tion and the ACP to potential residents when they are arranging admission to the Home. The team felt that this would generally be a time where there would be more engagement with relatives and also GPs. Hence, as this was a time where future care needs were being discussed, it would also be timely to include ACP. For the RACF, the practice of providing information about ACP and providing an ACP for completion on pre-admission to the Home is very new. Interestingly, the only resident admitted since adopting this practice had a completed ACP and Enduring Guardianship on admission. This was encouraging and may indicate that providing potential residents with the information and ACP will improve the uptake of ACP. New residents and relatives are asked to complete an ACP on admission if they havent already done so. If they appear reluctant to discuss this aspect of care at that time nurses leave the form with them and allow time to settle in and develop relationships with staff before revisiting subject. Of the seventy-one residents, eight do not have a completed ACP. One of these residents has dementia and little family contact. Interestingly, the remaining seven were recent admissions, and five of these have dementia. This may support the theory that residents and relatives need time to accept the residents changed situation and to develop relationships with staff.20 At the time of writing, thirty residents had not yet completed the new ACP, however, they have a completed previous version in their file. Of these residents, 19 have dementia, and 13 have little family contact. Given that residents with dementia are unable to complete an ACP,12 their end-of-life care will be directed by the information gathered on their previous End-of-Life Wishes form, and by their GP and RACF staff. Thirty-three residents have the new ACP completed and filed in their notes, and six have already been reviewed as the residents condition changed. Four residents completed an Enduring Guardianship at the same time. Ten of these thirty-three residents have dementia, and all of these residents have regular family contact.

Figure 1: Pre and Post-Implementation Results


90 80 70 60 Percent 52.1 50 39.4 40 30 20 14.1 10 0 1 2 3 Criteria 4 57.7 95.8 100.0 100 88.2 Audit 1 Your Performance

Audit 1

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39 Evidence in Action

It is argued that comprehensive ACP occurs over time (3-18 months)25 and therefore ongoing discussion with residents and relatives is required to ensure the ACP reflects the residents wishes.8 The results of this project indicate that in situations where residents have regular family contact, and therefore staff have regular opportunities to discuss ACP with them, an ACP is more likely to be completed. Given that the nurses initially described feelings of discomfort in discussing ACP, and that some residents and relatives had been reluctant to discuss end-of-life care, it was evident that there were barriers that needed to be addressed. The literature suggests lack of time, personal discomfort in talking about death, lack of knowledge about ACP, or a paternalistic view of endof-life care decision making may all be barriers to ACP.8 Further, many people have an intense aversion to contemplating mortality, which is then evidenced by anxiety, denial, fear, and avoidance.26,27 Many of these barriers may be reduced through openness and education.20, 25, 27 Therefore, the main strategies adopted by the project team were to initially provide formal education sessions, written material, and encouragement of an environment open to discussion around end-of-life care planning.

where best practice criteria were not being met. Following implementation of the strategies, a second audit (Phase four) was conducted to measure the effects of the implementation project on practice change. The results of the project have been prepared for publication (Phase five). The project was conducted over a relatively short period, however the results to date have been encouraging. Following the pre-implementation audit it was evident that the form the RACF was using did not capture the information required to meet best practice criteria. Subsequently, the form was reviewed and a new form was created to meet the needs of the RACF, the RHH and meet best practice criteria. As the post-implementation audit showed, significant improvement had occurred for the criteria around education, by providing skilled educators to present training sessions to residents and relatives, and separately to nurses. Written material was sent to all relatives to further promote education and ACP. It is envisaged that over time, all residents will have a completed revised ACP in their file, thereby extending their autonomy if they are unable to make or convey their wishes themselves at the end of life.

sponsibilities. The Australian health consumer. Number two 2005 2006. 6. Beigler, P., Stewart, C., Savulescu, J., & Skene, L. (2000). Determining the validity of advance directives. MJA, 172: 545-548. 7. Eastern Health. Respecting patient choices. Why plan in advance? http://www.easternhealth.org.au 8. NSW Department of Health. Using advance care directives. 2004. 9. Mogg, M. (2006). Advance care planning: The right to decide. ANJ, Vol 13 No 8. 10. Lyon, C. (2007). Advance care planning for residents in aged care facilities: What is best practice and how can evidence-based guidelines be implemented? Int J Evid Based Healthc, 5: 450-457. 11. Evans, J. (April 2003). Advance care planning: A review of the literature. Eastern Health Victoria. 12. Alzheimers Australia. Legal planning and dementia. Position paper 5. April 2005. 13. White, C. (2005). An exploration of decision-making factors regarding advance directives in a long-term care facility. Journal of the American academy of nurse practitioners, Vol 17; Issue 1: 14-20. 14. White, C. (2005). An exploration of decision-making factors regarding advance directives in a long-term care facility. Journal of the American Academy of nurse Practitioners, Vol. 17, issue 1. 15. McAuley, W. J., Buchanan, R. J., Travis, S., Wang, S., & Kim, M. S. (2006). Recent trends in Advance Care Directives at nursing home admission and one year after admission. The Gerontologist, 46, 3:377-381. 16. Lyon, C. (2007). Advance care planning for residents in aged care facilities: What is best practice and how can evidence based guidelines be implemented? Int J Evid Based Health, 5: 450-457. 17. Conroy, S., Chin, S. K., & Lo, N. (June 2005). Advance directives: Awareness in care homes. British Journal of General Practice. 18. Alzheimers Australia. Decvision making in advance: Reducing barriers and improving access to advance directives for people with dementia. Discussion paper 8, May 2006. 19. The Royal Australian College of General Practitioners. Medical care of older persons in residential facilities. 20. Bialk, J. L. April 2004). Ethical guidelines for assisting patients with end-of-life decision making. Medsurg Nursing, 13,2; Health and medical Complete pg. 87. 21. McAuley, W. J., Buchanan, R. J., Travis, S. S., Wang, S., & Kim, M. S. Recent trends in advance directives at nursing home admission and one year after admission. The gerontologist, Vol. 46, No. 3, 377-381. 22. Pearson, A., Schultz, T., & Conroy-Hiller, T. (2006). Developing clinical leaders in Australian aged care homes. Int J Evid Based Healthc, 4: 42-45. 23. The Joanna Briggs Institute. Practical Application of Clinical Evidence System. PACES user guide. 2006. 24. Jamtvedt, G., Young, J. M., Kristoffersen, D. T., Thomson OBrien, M. A., & Oxman, AD. Audit and feedback: effects on professional practice and health care outcomes (Review). The Cochrane Library 2005, Issue 4. 25. Guidelines for a palliative approach in residential aged care. Chapter 4 Advance care planning. 26. Foley, K. M. Transforming the culture of dying. Project on death in America. 27. Gire, J. T. Online readings in psychology and culture, Unit 14, Chapter 2.

Conclusion
ACP is an important part of holistic care in Residential Aged Care facilities. An ACP can extend an individuals autonomy when they are unable to make or convey their wishes themselves. When providing endof-life care, residents, relatives, and nurses all benefit when wishes for treatment have been discussed and documented. An audit identified that the completion of ACP in the Nursing Home was inconsistent, and that this would be an ideal area of focus for the JBI Evidence-Based Clinical Fellowship project. The project was undertaken in five phases: Phase one being identification of an area which needed improvement, and identification of best practice audit criteria. Phase two utilized PACES to complete a baseline audit, which determined to what degree the RACF complied with the best practice criteria. Phase three utilized GRIP to identify and implement strategies to facilitate practice change

Ethical Considerations
Ethics Committee approval for this project was not required. The project comprised of audits of current clinical practice and documentation, rather than drawing on residents as the sample of interest. The information obtained formed aggregative data presented in one report, which tracked the audit indicator. Confidentiality was maintained by the safe storage of the data collected, and anonymity was maintained as no identifiable data was collected.
References
1. University of Michigan health system. Health topics A-Z Advance Directives/Living wills. http://www.med. umich.edu/1libr/aha/umadvdir.htm 2. Ashby, M. A., Kellehear, A., & Stoffell, B. F. (2005). Resolving conflict in end-of-life care. MJA, 183 (5): 230-231. 3. Vincent, J. L. (2001). Cultural differences in end-oflife care. Crit Care Med, Vol. 29, No. 29 Suppl. 4. Yeo, J. D. Advance care directives Living Wills Forum. Law Week Forum, Law Society 31st March, 2006. 5. Cartwright CM. Advance care planning: rights and re-