1290 Written emergency guidance – Germany’s struggle to reach a consensus on planning and documenting for medical emergencies

<h3>Background</h3> Planning ahead what goals to follow and what (if any) treatment measures to ban in case of a life-threatening medical emergency going along with decisional incapacity is one central aspect of advance care planning (ACP). However, there is still large variation both within and between countries, and little consensus what should and what should not be part of written emergency guidances. <h3>Aim</h3> To describe the development and rationale of the written integrated emergency guidance endorsed by Advance Care Planning Germany and, similarly, ACP Suisse, its structural differentiation from other published approaches to emergency guidance, available empirical data on its clinical acceptance and use, and Germany’s ongoing struggle to agree on a national format of such a guidance. <h3>Methods</h3> Description and analysis of the rationale and composition of the integrated emergency guidance, developed in the past two decades by a binational German-Suisse working group; overview on given empirical research with this document; and review of international publications in the field. <h3>Results</h3> The written integrated emergency guidance (Integrierter Notfallplan) is limited to one sheet that integrates the documentation of the individual patient’s treatment goals, derived from this person’s views on living, severe illness and dying, on one page, and a concise choice of one out of six emergency options (ranging from A = use all available acute care options to sustain life to C = refrain to palliative care only) overleaf. The written guidance is to be signed by the patient (or, if incapacitated, his/her proxy), the designated proxy if given, the ACP facilitator, and the treating physician. Formally, the patient’s signature denotes this document as an advance directive which in German law strictly binds all health professionals if applicable to a given clinical situation. Empirical data show that the document can be implemented in nursing homes, and that residents‘ preferences are distributed over all six options. The document somewhat resembles its model, the US POLST form, but is unique internationally in that it strictly refers to patient autonomy, not medical prognosis, combines the documentation of treatment goals and (overleaf) treatment choices on one sheet, and focuses on six steps that precisely define escalation of acute medical care. <h3>Unique Contribution</h3> Elements of a rationale for national written emergency guidances is provided. <h3>Implications</h3> An international consensus on ACP and written guidance for medical emergencies, endorsed by ACP-i, would greatly strengthen and support efforts to come to action on a national level.