Mary Anne Huggins, MD, CCFP, DABHPC, Palliative Care Services, Toronto General Hospital, University Health Network; Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON.
Laura Brooks, BScN, MScN, ACNP, Palliative Care Services, Toronto General Hospital, University Health Network, Toronto, ON.

Discussing end-of-life care with older patients is very important, as it ensures their preferences are known and they retain control over their care decisions even when they may no longer be actively involved in them. Unfortunately, these discussions do not always occur, and when they do occur, they are not always done well. There are patient and physician barriers to advanced care planning. Physicians may lack the skills necessary to accomplish the task of making decisions for future care. In this article we discuss advanced care planning, its importance as well as related challenges and barriers. We then outline a practical approach to advanced care planning for older adults.
Key words: end-of-life care, advance directives, advanced care planning, living wills, substitute decision-maker.

Michael Gordon, MD, MSc, FRCPC
Vice President of Medical Services,
Baycrest Centre for Geriatric Care,
Professor of Medicine,
University of Toronto, Toronto, ON.

The nurse and physician were very upset. They felt that Mrs. B.'s daughter was not respecting her mother's wishes to forgo CPR should she experience a cardiac arrest. A year earlier, when Mrs. B. entered the nursing home with late-stage Parkinson's disease, she had filled out an advance directive, naming her daughter, rather than her ailing husband, as her surrogate and indicating that, in the event of a cardiac arrest, she did not want to be resuscitated. Over the course of the year, as her disease progressed and she underwent repeated aspirations, it became evident that the end was in sight. Mrs. B.'s daughter told the staff that she would not accept the DNR order and, as the "lawful" surrogate, was requesting that "everything" be done should her mother have a cardiac arrest.

Dr. M. was distraught. Six months earlier, he and his younger brother and sister had, with some reluctance, agreed to the insertion of a PEG tube for their mother who suffered from late-stage Alzheimer disease and had stopped eating after a bout of pneumonia. They felt that by feeding her, she might have a chance at recovery and had not really thought through the long-term consequences of their decision.