Advance Care Planning in Brazil.

Brazil is a country of continental size marked by extreme social inequalities. Its regulation of Advance Directives (AD) was not enacted by law but within the scope of the norms that govern the relationships between patients and physicians, as a resolution of the Federal Medical Council without any specific requirement for notarization. Despite this innovative starting point, most of the debate regarding Advance Care Planning (ACP) in Brazil has been dominated by a legal transactional approach focused on making decisions in advance and the creation of AD. Yet, other novel ACP models have recently emerged in the country with a focus on the creation of a specific quality of relationship between patients, families, and physicians aiming at the facilitating future decision-making. Most of the education on ACP in Brazil happens in the context of palliative care courses. As such, most ACP conversations are performed within palliative care services or by healthcare professionals with training in that area. Hence, the scarce access to palliative care services in the country means that ACP is still rare and that those conversations usually happen late in the course of disease. The authors posit that the existing paternalistic healthcare culture is one of the most important barriers to ACP in Brazil and envision with great concern the risk that its combination with extreme health inequalities and the lack of healthcare professionals' education on shared decision-making could lead to the misuse of ACP as a form of coercive practice to reduce healthcare use by vulnerable populations.

How should Argentina raise Advance Care Planning awareness? Introduction of the Shared Care Planning Group.

The WHO Concept Model of Palliative Care emphasises empowering people and communities with Advance Care Planning (ACP). In Latin America, a more relational approach involving family members is suited to ACP. Improvements in doctor-patient-family relationships are needed. Policy efforts have been made to foster ACP in Argentina's healthcare system, but implementation barriers include a need for more communication skills and coordination between healthcare providers. The Shared Care Planning Group Argentina aims to promote ACP through research and training programs. It has sensitised and trained 236 healthcare providers in short courses to introduce basic information and skills. However, there needs to be specific documentation for ACP in Argentina. Research found obstacles to ACP implementation, such as the inability to converse with patients and the lack of coordination between healthcare teams. A new project will assess the self-efficacy of healthcare professionals who assist patients with Sclerosis Lateral Amyotrophic in ACP and evaluate a specific training program. Patient and public involvement in ACP remains limited in Argentina, with paternalistic medical culture and a need for more awareness and training among healthcare professionals as significant barriers. Collaborative research projects with Spain and Ecuador aim to train healthcare professionals and evaluate ACP implementation in other Latin American countries.