Advance directives, perioperative care and end-of-life planning

It is ethically and legally important, when providing care to our patients, to respect their autonomy and dignity, to act in their best interests and avoid doing harm. Advance care planning is essential to achieving this by giving patients the opportunity to tell us what they would want us to do if they became seriously unwell and could no longer communicate their wishes. Whereas earlier attempts at advance care planning focussed on the completion of forms, the more recent, successful focus has been on the patient-centred discussion, involving family, appointment of substitute decision makers and identification of what the patient would see as an acceptable outcome from any proposed treatment. Advance care planning is successful in caring for the elderly, including in the perioperative setting. There is an increasing focus on improving end-of-life care, including the prevention of suffering, making earlier and wiser end-of-life decisions about the appropriateness of treatment and improving communication with patients and families. New awareness of the poor outcomes from cardiopulmonary resuscitation (CPR) is catalysing reassessment of the appropriateness of this intervention.