Advance Care Planning

Key messages

Advance care planning is a right of all people, and is an ongoing, valuesdirected discussion involving health professionals, patients, and their
family or other agent.

Patients expect and are happy for their doctors to initiate conversations
about advance care planning however the conversations may often be
performed by other health professionals.

Advance care planning requires that patients are given accurate and
sensitively provided information about their illness and health care
options and prognosis; opportunities to discuss their wishes with their
doctors and their chosen decision-maker/s; and that their wishes are
accurately documented, regularly updated, and can be accessed as
needed.

Encouraging patients to choose a surrogate decision-maker, and discuss

their values and preferences with them, is an important component of
advance care planning. The surrogate decision-maker also requires
support and information to fulfill this role.

Advance care planning should begin early in a patient's illness, and be a

part of routine clinical care, sometimes completely healthy individuals
want to do advance care planning.

Health system processes are crucial for effective advance care planning,
and health system-wide changes are likely to be needed for advance care
planning to become an integral part of routine clinical care.

Statutory processes that formalise the role of written advance directives

and of surrogate decision-makers vary in different states.

Background

Advance care planning is the process by which patients make decisions that can
guide their future health care, if they become unable to speak for themselves. It
is based on the ethical principle of respect for patient autonomy. Advance care
plans reflect patients own values and concerns, and require patients to
understand their medical condition, and also the benefits and burdens of
possible treatments. They are important in guiding decision-making at the time
when a patient is too unwell to make their own decisions, or is unable to
communicate.
Advance care planning requires conversations between patients, their doctors,
and their surrogate decision-makers about how they would like to be cared for,
and so the communication skills of health care providers are a very important
factor in their success. Advance care planning can include the use of formal
advance directives which are written documents that may be legally binding to
varying degrees in different states (e.g. a Refusal of Treatment Certificate in
Victoria, an Advance Health Directive in Queensland, and the Natural Death
Certificate in the Northern Territory). Nonetheless, advance care planning
documentation of a patient's wishes - can also occur without using these legal
processes.
Some of the major factors that are important for advance care planning will be
covered here:

Surrogate Decision-Makers
There is significant burden associated with the role of surrogate decision-maker.
[1]
A systematic review examining how well surrogate decision-makers predicted
the patients wishes showed that they were accurate in two thirds of the cases.
It was suggested that accuracy may not be the only benefit which is important
to patients when relying on patient-designated surrogates. [2]
Relationships between health care providers and family members, and amongst
the family members themselves, have a significant impact on those who
participate in end of life decision making. [3] An important area of potential
conflict with surrogate decision-makers is in the care of critically children. [4]

In regard to the role and use of surrogate decision-makers, there are significant
differences between practices in different national health systems, based on
how much focus there is on patient autonomy, the amount of formal reliance on
surrogate decision-makers, and the extent to which medical predominance in
decision-making is regarded as acceptable or as paternalistic. [5]
In some cultures family-centered decision-making is valued much more highly
than patient autonomy. [6]

What it means in practice

The role of the surrogate decision-maker is to try to ensure that any

decisions which are made about the patients care are consistent with
what is known of the patient's own values and wishes, and they should
adhere to any documented advance care plan. This may be difficult for
family or friends who are dealing with their own impending loss.

Surrogate decision-makers experience considerable stress in their role of

supporting the patient. In order to perform this role they need a very
supportive relationship with the health care providers caring for the
patient, and adequate information. Distress is often a factor in conflict
over end-of-life decisions.

Whilst formal arrangements for proxy decision-making focus on named

individuals who are appointed as surrogates, in practice many families
make collective decisions. In some families, there can be resistance to
disclosing diagnosis and prognosis to the patient, which makes advance
care planning very difficult. Skilled and sensitive communication is
required to deal with these conflicting perspectives, whilst at the same
time ensuring that patients and families own values are respected.

Patient Management

Assessment and management of physical symptoms is a major

focus of palliative care, as poorly controlled pain or nausea can
seriously affect a patient's quality of life. It can also reduce their
ability to maintain physical functioning which then affects all

aspects of their daily life. Symptoms in this section include items

from the symptom assessment scale [1] used in the Palliative
Care Outcomes Collaborative.
Moreover, the definitions of palliative care by both the World
Health Organization and Palliative Care Australia recognise that
suffering may not only be physical, and that care needs to include
psychological, spiritual and social care and support. Providing
comprehensive care requires an understanding of the specific
needs and circumstances of the individual patient.
Appetite Problems
Anxiety
Bereavement and Grief
Breathing
Complementary Therapies
Constipation
Delirium
Depression
End-of-life Care
Fatigue
Nausea
Pain
Sleeping Problems
Social Support

 Suffering.
The pages are developed following an examination of the
research evidence for the symptom as described in systematic
reviews relevant to the topic. The systematic reviews were
identified following a search for topic based systematic reviews in
four databases - OvidSP MEDLINE, CINAHL, PsycINFO and Embase.
Reference
1. Kristjanson LJ, Pickstock S, Yuen K,
Davis S, Blight J, Cummins A, et al.
Development and testing of the
revised Symptom Assessment Scale:
Final report. Perth; Edith Cowan
University: 1999.
Last updated 2 May 2013

PubMed Searches
Appetite Problems
Free full text only

Strongest
Evidence
Everything
All citations

Appetite Problems

Key messages

Strongest
Evidence
Everything
Last 3 months
About these Searches

Whilst clinical research on cachexia

and anorexia has mostly focused on
weight gain, on its' own this may not
result in meaningful changes for
palliative care patients. [1]

Review Collection

Weight Loss

There is evidence to support the use of

either progestogens (megestrol acetate or
medroxyprogesterone acetate) [2] or corticosteroids [3] as
appetite stimulants in advanced cancer.
Systematic reviews of the role of dietary polyunsaturated
fatty acids (eicosapentaenoic acid -EPA and docosahexanoic
acid -DHA) as a supplement in cancer cachexia have not
shown any benefit. [4-5]

 Guidelines for managing anorexia and cachexia in advanced

cancer patients are available. [6]
Overview
Loss of weight (cachexia) and appetite (anorexia) are significant
concerns for many palliative care patients, and independently
predict a poorer prognosis. [7-8]
The palliative conditions in which cachexia and anorexia occur
most frequently are progressive malignancy, HIV/AIDS, end-stage
cardiac failure, end-stage respiratory failure, chronic renal failure,
chronic liver disease, and advanced dementia.
Potentially reversible contributors to appetite problems should be
sought, and treated as appropriate. These may include:
Mouth problems mucositis, oral thrush
Nausea
Pain
Dysphagia
Constipation
Depression
Family, social and cultural expectations related to food, diet,
and body weight
Inappropriate presentation of food
De-conditioning / reduced level of activity
Changed sense of taste and smell
Malabsorption

PubMed Searches

Dyspnoea

Anorexia

Medication effects.
Issues related to appetite that are covered
in this section are:
Cachexia anorexia syndrome
Appetite stimulants
Artificial nutrition.

Free full text only

All citations

Cachexia Anorexia Syndrome

The cachexia anorexia syndrome is a

complex metabolic syndrome associated
with cancer and some other palliative
conditions. Cachexia has been defined as
involuntary weight loss involving both fat
and muscle, due to shifts in metabolism
caused by tumour by-products and
cytokines. [1]

Strongest
evidence
Everything

Strongest
evidence
Everything
Last 3 months
Cachexia
Free full text only

Strongest
evidence
Everything
All citations

Strongest
evidence
Everything
Last 3 months

Although the definition of the syndrome

varies, symptoms that are usually identified About these searches
as part of the cachexia anorexia syndrome
Review Collection
include weight loss, anorexia, early satiety,

Anorexia cachexia
fatigue, weakness, anaemia, inflammation
and low albumin. [2-3] Nutritional
assessment tools that include markers of
inflammation are being investigated. [4] Their role in clinical
practice may be to identify patients earlier in the palliative
trajectory, and be incorporated into clinical practice guidelines
about management of the syndrome. [5]
What is known

The detailed neurophysiology of appetite / anorexia is not well

understood in humans. It may be different from the mechanism of
cachexia / weight loss. [6]
The metabolic profile of cancer cachexia is not the same as that
of starvation, which is defined as secondary cachexia. Cancer
cachexia involves inflammation, hypermetabolism, neurohormonal changes, and the production of proteolytic and lipolytic
factors. [2-3]
Appetite loss occurs in over half of all palliative care patients, and
weight loss becomes more common in the last weeks and months
of life. [7]
Loss of weight and loss of appetite do not always occur together.
Some patients have cachexia despite maintaining a relatively
normal appetite and nutritional intake. [3]
Loss of weight and appetite due to cancer progression have
prognostic relevance for symptom burden, performance state,
survival, and the ability to tolerate palliative chemotherapy. [2]
Cachexia may also be a prognostic factor in non-malignant
conditions. [8]
What it means in practice
Appetite is a subjective symptom. Simple assessment tools
are available, such as the Symptom Assessment Scale, which
is part of the PCOC dataset.
A simple and valid nutrition assessment tool used in research
and practice is the Patient Generated Subjective Global
Assessment, which has been used in cancer cachexia and is
recommended in evidence based practice guidelines for
nutritional management of cancer cachexia. [9]

 Eating and food have great social, cultural and psychological

significance for patients and their families, and issues
relating to nutritional support are often socially and ethically
complex. [10-12]
If an underlying malignancy can be effectively treated, this is
likely to reverse the cachexia anorexia syndrome.
In patients who have advanced dementia, loss of appetite
and decreasing oral intake may be a marker of the transition
to end-stage disease, although contributing factors should
be sought and addressed as appropriate. [13] Families of
patients with end-stage dementia may require increased
support as they deal with this change. [13] Artificial nutrition
(tube feeding) has not been shown to improve life
expectancy in patients with end-stage dementia. [14]

Principles of Medical Ethics

Preamble
The medical profession has long subscribed to a body of ethical statements developed
primarily for the benefit of the patient. As a member of this profession, a physician must
recognize responsibility to patients first and foremost, as well as to society, to other
health professionals, and to self. The following Principles adopted by the American
Medical Association are not laws, but standards of conduct which define the essentials of
honorable behavior for the physician.

Principles of medical ethics

I. A physician shall be dedicated to providing competent medical care, with compassion
and respect for human dignity and rights.
II. A physician shall uphold the standards of professionalism, be honest in all professional
interactions, and strive to report physicians deficient in character or competence, or
engaging in fraud or deception, to appropriate entities.
III. A physician shall respect the law and also recognize a responsibility to seek changes in
those requirements which are contrary to the best interests of the patient.

IV. A physician shall respect the rights of patients, colleagues, and other health
professionals, and shall safeguard patient confidences and privacy within the constraints
of the law.
V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a
commitment to medical education, make relevant information available to patients,
colleagues, and the public, obtain consultation, and use the talents of other health
professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies,
be free to choose whom to serve, with whom to associate, and the environment in which
to provide medical care.
VII. A physician shall recognize a responsibility to participate in activities contributing to
the improvement of the community and the betterment of public health.
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as
paramount.
IX. A physician shall support access to medical care for all people.
Adopted June 1957; revised June 1980; revised June 2001.

Withholding and Withdrawing Treatment

'Euthanasia and assisted suicide are different from withholding or withdrawing
life-sustaining treatment in accordance with good medical practice by a medical
practitioner. When treatment is withheld or withdrawn in these circumstances,
and a patient subsequently dies, the law classifies the cause of death as the
patients underlying condition and not the actions of others'. [1]
Decision making at the end of life can often involve very difficult and emotional
decisions about whether to start or stop a treatment. For example, whether or
not to start mechanical ventilation or whether to stop PEG feeding. These
decisions need to consider whether something is burdensome for the patient in
other words, quality of life.
Nurses are often involved in the debates surrounding the withholding or
withdrawal of treatment and there are often conflicting views in decision
making. Ethical, cultural, religious and moral factors are enmeshed in these

decisions and there are also sometimes worries about legal implications. [2] One
study in an ICU setting found that central to the theme of withdrawing treatment
was working with the family; consistent communication is a key factor. [3]

Ethical Issues
Much of the daily work of nurses in end-of-life care could perhaps be thought of
as overlaid with ethical issues. This may be in relation to concerns that are
raised, or with requests or decisions that are made. This section provides
information and resources on some of the ethical issues that nurses can
encounter in end-of-life care.

Assisted Suicide

Autonomy

Euthanasia

Nutrition and Hydration

Palliative Sedation

Research

Resuscitation

Truth Telling and Collusion

Withholding and Withdrawing Treatment

Assisted Suicide

Assisted suicide is to deliberately help or encourage someone to

end their life. (Euthanasia is the act of deliberately ending
someones life to relieve their suffering).
Palliative care is aimed at supporting people at the end of their
life. This may include for example, withholding or withdrawing

futile treatment, which is not considered to be euthanasia or

assisted suicide. Lawful care of terminally ill patients, such as
withholding or withdrawing futile treatment, never involves an
intention to end a patients life.
Nurses working in palliative care are sometimes asked to help end
someones life: 'I cant go on like this, can you give me something
to end it all?' Patient assisted suicide has been described as 'the
provision of drugs and/or advice so that a patient could take his or
her own life'. [1] This is illegal in Australia. [2]
It is important to acknowledge that some patients are expressing
a desire to die rather than requesting direct action. These
requests to die can be made when someone is depressed or
emotionally distressed. For example they may feel that they are a
burden, or perhaps are suffering intolerable physical or emotional
symptoms. At other times decisions have been made carefully,
such as deciding that life is intolerable.
One study of terminally ill patients in Canada [1] found that the
desire for death was transitory (dependent upon symptoms at the
time). This indicated that potentially treatable symptoms could in
fact, drive people to suicide. Further research, on who is choosing
an assisted death and why, is needed. [3]
If someone is talking about taking their own life, whether or not
they are asking for help to do it, this situation needs to be
addressed urgently. Actively listening to their concerns and fears
can help ascertain why they have come to make this request.
Talking to others within the health care team whenever possible
provides a multidisciplinary approach to a situation that shouldnt
rest with one practitioner.
Autonomy

Autonomy is about a persons right to make their own decisions.

To do this effectively, they need to have enough information.

Patients do not always fully understand what they have been told,
or they may not have been told. [1] Decisions are best made
without undue influence, and the person making the decision
should also be deemed capable of doing so.
Patient choice and autonomy are considered key in palliative care.
Part of the nurses role, wherever possible, is to advocate for a
competent patients right to decide their own course of action,
whether it is something that the nurse feels is appropriate or not.
Decision making is complex and includes cultural and social
aspects that are not always acknowledged. [2]
It may be difficult to stand by when a patient decides (sometimes
against advice) to take a course of action that is not considered
acceptable or appropriate. However, if the patient is capable of
making such a decision and is well informed of the consequences
of their actions, they must be allowed to exercise their autonomy
to do so.
Palliative care patients are often vulnerable and may be more
easily persuaded to make choices that they would not normally
make, such as accepting further treatment that they dont really
want. They may also continue to request treatment that they
have been told is futile and may not help. Further examination of
their understanding of the situation and their goals is required to
help support them in their decision making.
Euthanasia

Euthanasia is a deliberate act or omission, undertaken with the

intention of ending a persons life. Euthanasia is illegal in all
Australian states and territories. (Assisted suicide is to
deliberately help or encourage someone to end their life.)
Euthanasia has been an ever present debate in palliative care.
The last two decades have seen a rise in active pro-euthanasia
advocates pushing for legislation across the world. However,

palliative care is aimed at supporting people at the end of their

life, and this never involves an intention to end a patient's life.
A request for euthanasia sometimes comes from family members.
Nurses may be asked by families to give their loved one
something to 'end it all'. This may be when the person is
unconscious or in the final days of life, and appears
uncomfortable, as if they are suffering. Families will sometimes
draw comparisons with the humane treatment of animals who are
considered to have intolerable suffering.
Any request for euthanasia need to be addressed, regardless of
the source or nature. Actively listening to the concerns and fears
of the person can help ascertain why they have come to make
this request. Talking to others within the health care team,
whenever possible, also provides a multidisciplinary approach to a
situation that shouldnt rest with one practitioner.
Nutrition and Hydration

Providing food and fluids has great meaning to many people as

they often relate the provision of food and fluids to comfort and
nourishment, and to the giving and preserving of life. A persons
cultural background can have great impact on their values and
beliefs regarding this topic and should never be underestimated.
Providing food and fluids for as long as someone wants them and
can safely take them is important. It is when the person can no
longer take them that the complexities of ethical decision making
arise. This can be an emotive issue for nurses as well as for
families.
Some family members insist on trying to continue to feed their
loved one even when it is no longer safe to do so. They may
consider not doing this as a failure to care. They may also insist
on parenteral fluids or a feeding tube once someone can no
longer eat or drink. In these circumstances it is important to talk

to them about comfort measures, such as regular mouth care,

wetting the patient's lips and using lip balms. If the family are so
distressed at the thought of dehydration, a small amount of
subcutaneous fluid may be an acceptable compromise.
Other health professionals are a good resource. For example, if
unsure whether someone can still safely swallow food and fluids,
referral to a speech therapist would be helpful.
Some patients themselves choose to specifically request not to
receive artificial nutrition or hydration at the end of their life, such
as in an advance directive. Some may make this choice at the
time, with or without the agreement of their relatives.
Artificial nutrition and hydration are seen by some as
interventions in what should be a natural process. They may be
easy to initiate but there can be difficulties when the time comes
to consider their withdrawal. All discussions should take place
early with families, ensuring they are aware of burdens and
benefits of continuing this therapy.
Palliative Sedation

Palliative sedation is regarded as the use of sedation until death

in the terminal phase, for symptoms that are resistant to other
treatment measures. [1]
The decision to prescribe and/or administer palliative sedation
should not be taken lightly, and is considered to be a last resort
once all other measures have been exhausted. It is considered
appropriate for only a small group of patients and used, for
example, for intractable symptoms. Establishing that a symptom
is intractable (or impossible to control) is the first step in this
process, with the associated collaborative decision making of vital
importance.

Making this decision may create debate and contention within the
multidisciplinary team. This mainly lies with the intention and
depth of sedation, and in palliative sedation corresponding with
withdrawal of other treatment. One example of this is whether the
patient or family are making the request.
It is important to emphasise that palliative sedation does not have
the intent to directly hasten or end life, although some argue that
the lines between palliative sedation and euthanasia can be
blurred in cases where sedation is introduced too early or if
medication doses are disproportionately high. [2] Another study
found a lack of consensus in defining existential suffering due to
its subjective nature and therefore difficulty in deciding on an
appropriate treatment course. [3]
If palliative sedation is a consideration then seek advice and
support where possible from a specialist palliative care service.
Research

Palliative care research is helping to identify best practice for the

care of the dying. Palliative care patients have long been
considered a vulnerable population, and for many years it was
considered unethical to conduct research with those at the end of
life. [1]
In more recent years it has been reasoned that facilitating
participation in research has allowed these patients to continue to
have a voice, and to contribute to the care of those that will
follow. However, not everyone takes this view. Some family
members feel that they should protect patients from distress or
further burden by not allowing them to participate in research.
Some health professionals hesitate to propose them as a potential
research subject. Talking through the benefits of research (and the
ability to withdraw at any time) to those who are protecting
them may help to alleviate their concerns. One study describes
compassion and vigilance as themes when investigating

strategies that researchers have employed to manage ethical

concerns in end-of-life research. [2]
Ethical concerns surrounding research with vulnerable populations
include issues of consent; the resources and literature listed here
may be of help.
Resuscitation

There has been much discussion over the years about

resuscitation in the setting of hospice and palliative care.
Resuscitation should be part of broader discussions around
advance care planning with patients and their families. These
discussions should be facilitated as early as possible, although in
reality they continue to occur late in the illness trajectory, and
sometimes are only raised when death is imminent. One study
highlighted the fact that patients are not always aware of their
prognosis; therefore, if resuscitation is discussed early in the
course of their illness, decision-making around resuscitation will
improve. [1] Another study found that the provision of written
information about resuscitation was acceptable to patients but
needed to be accompanied by a discussion regarding prognosis.
[2]
These discussions (and subsequent decisions regarding to
resuscitate or not to resuscitate) should always be clearly
documented to avoid confusion as the need to act on the decision
arises. Documentation includes not only case notes or community
notes, but also Advance Directives.
This situation will sometimes result in nurses not knowing
whether to undertake resuscitation attempts or not. This can be
especially difficult if for example, someone is imminently dying
and their family are advocating for resuscitation (whether
documentation is in place or not). Communication with patients
and their families around decision making needs to take place

early, so that these issues can be raised and conflicts potentially

avoided later.
Truth Telling and Collusion

Nurses are sometimes asked to withhold the truth from a patient.

This is referred to as collusion, and can easily create a scenario of
secrecy and mistrust. These requests are often made in relation to
disclosing a life-limiting illness such as cancer, or even imminent
death, and can be made by a family member or by the patient
themselves.
In western society, it was common in the past to exclude a patient
from the truth, but the trend has moved away from this in recent
years. However in many cultures, it may still be common practice
to keep distressing news from patients. Illness can be viewed as a
family concern and autonomy may not be recognised. [1] In these
instances it is important to understand and respect the cultural
beliefs and collaborate with an elder or significant person, while
keeping the patients interests foremost. The ethical principles of
beneficence (to do good) and non-maleficence (to do no harm)
would apply.
The role of the nurse in this context is a difficult one. The majority
of patients prefer to be told the truth about what is happening to
them. Many will know or guess the truth and also realise that this
is being kept from them. Others will not want to know, and this is
their choice.
The nurse patient relationship will suffer if the patient feels that
they are being lied to or kept from knowing the truth. Culturally
acceptable communication is usually the best policy, and
discussions within the multidisciplinary team can help to clarify
what is happening, why it is happening and whether it is in the
best interests of the patient.

A useful framework for nurses to avoid potentially distressing

disclosures is to ask the patient: 'What do you know about your
illness and what is happening at the moment?' and equally
important: 'How much would you like to know?'
Withholding and Withdrawing Treatment
'Euthanasia and assisted suicide are different from withholding or withdrawing
life-sustaining treatment in accordance with good medical practice by a medical
practitioner. When treatment is withheld or withdrawn in these circumstances,
and a patient subsequently dies, the law classifies the cause of death as the
patients underlying condition and not the actions of others'. [1]
Decision making at the end of life can often involve very difficult and emotional
decisions about whether to start or stop a treatment. For example, whether or
not to start mechanical ventilation or whether to stop PEG feeding. These
decisions need to consider whether something is burdensome for the patient in
other words, quality of life.
Nurses are often involved in the debates surrounding the withholding or
withdrawal of treatment and there are often conflicting views in decision
making. Ethical, cultural, religious and moral factors are enmeshed in these
decisions and there are also sometimes worries about legal implications. [2] One
study in an ICU setting found that central to the theme of withdrawing treatment
was working with the family; consistent communication is a key factor. [3]

Advance Directives
What They Are And What They Do
WebMD Medical Reference from the National Hospice and Palliative Care
Organization

What are advance directives?

"Advance directive" is a general term that describes two types of legal
documents:

Living wills

Medical power of attorney

These documents allow you to instruct others about your future medical
care wishes and appoint a person to make healthcare decisions if you are
not able to speak for yourself. Each state regulates the use of advance
directives differently.

What is a living will?

A living will is a type of advance directive in which you put in writing your
wishes about medical treatment for the end of your life in the event you
cannot communicate these wishes directly. Different states name this
document differently: for example, it may be called a "directive to
physicians," "health care declaration," or "medical directive." Regardless of
what it is called, its purpose is to guide your family and doctors in deciding
about the use of medical treatments when you are dying.
Your legal right to accept or refuse treatment is protected by the
Constitution and case law. However, your state law may define when the
living will goes into effect, and may limit the treatments to which the living
will applies. You should read your state's suggested document carefully to
ensure that it reflects your wishes. You can add further instructions or write
your own living will to cover situations that the state suggested document
might not address. Even if your state does not have a living will law, it is
wise to put your wishes about the use of life-sustaining medical treatments
in writing.

What is a medical power of attorney?

A medical power of attorney is a document that lets you appoint someone
you trust to make decisions about your medical care if you cannot make
them yourself.
This type of advance directive can also be called a "healthcare proxy,"
"appointment of a healthcare agent," or "durable power of attorney for
healthcare." The person you appoint may be called your healthcare agent,
surrogate, attorney-in-fact, or healthcare proxy. The person you appoint
through a medical power of attorney usually is authorized to deal with all
medical situations, not only end-of-life decisions when you cannot speak for
yourself. Thus, he or she can speak for you if you become temporarily
incapacitated-after an accident, for example-as well as if you become
incapacitated because of irreversible disease or injury.
Home tips
1) There should be no shoes or slippers lying around outside the main door of your house.
Remove it if you can. Allow that space at the main door to be free and clear. The chi
(energy) rides with the wind and will collect all the smell of those shoes and slippers into
your house causing sickness. Chi then travels about in your house looking for water to stay
but if there are no water fountains or fish tanks, then the Chi will be dispersed by wind.
2) There should be no television sets in your bedrooms: If you cannot get rid of that habit
then after watching the television cover it with a plastic table cloth. Remember it has to be
plastic and not simply cloth.
3) There should be no mirrors opposite your bed or at the side of your bed. Mirrors opposite
the bed can attract a third party to the relationship. Therefore, do not place mirrors
anywhere you like and especially in your bedroom.
4) Place an indoor water fountain in your home, position in a favourable area to attract
whatever you want in your life.
5) If you already have a fish tank in your house, be careful. A fish tank placed correctly can
bring about greater fortune, as you will tap on the Divine Water Dragons Den. But if you
tap wrongly, it can cause you to have lawsuits, bankruptcy, work pressure, troubles and
problems. If you noticed any of these after placing the fish tank for approximately four
months, shift your fish tank to another location.

6) In your kitchen, ensure that opposite your stove there is no refrigerator, washing
machine, washbasin and toilet. The fire and water crash causing family members to have
disagreements.
7) Try not to allow children to sleep on mattresses on the floor. Yes, this allows young
children not to fall off beds but it also causes young children to fall sick frequently. The
reason is: chi is not able to flow underneath the bed. Ideally, chi should circulate around the
mattress where our children sleep to allow them to be healthy.
8) For young children, try to have their back to the wall when they write. It is important there
should be a solid wall behind a childrens writing table. This allows the child to have support
so that he can sit there and study longer rather than for only half an hour and then they tend
to move about because there is no solid wall behind their back. Adjust your writing table.
9) Do not allow children to sleep on double bunk beds even if it means saving space. The
child sleeping underneath will not have fresh chi and so his health might be weak. But if
due to space constraints, then monitor your childs health if not add in a metal 6 rods wind
chime or a crystal sphere, to break up the stale chi around his bed.
10) Your bed should always have a solid wall behind you. This is important if you wish to
have a good rest. A solid wall simply means that you can go into deeper sleep and therefore
enabling you to have good rest so that when you wake up in the morning, you will feel fresh
and well rested. This also allows you to be able to concentrate on your work better.
11) There should be no beam on top of your bed. The beam above causes chi to be
pressured thus enabling you to have pressures in life. Therefore, dont place furniture
underneath it or alternatively level the beam. But make sure if you choose the latter, it is
important that you have enough height for that space.
12) If you have a lot of work pressure, maybe its the marble table that you have in your
dinning room that causes you to have those problems. Remove that marble table and
change to a wooden one or alternatively live with that work pressure!
13) If your child usually falls sick in that bedroom: Then either change them to another
bedroom or simply hang a six rod metal wind chime as the metal element will break all the
earth energies in that room. After hanging, if the wind could not do the job for you then you
will have to chime it yourself and then watch for the good results.
14) Do not use a red sofa set: The colour red represent the element of fire. And for Feng
Shui, some places simply cannot have the colour red in that sector. For example: the wealth
area or some other sectors which without a Feng Shui check would be unable to tell you
where it is. A red sofa sets gives rise to heavy work pressure, troubles and obstacles.
15) Always open your bedroom windows at least once 20 minutes a day to allow fresh chi to
come in, we do this so that it allows fresh new chi from outside to come into your bedroom,
if not you will be sleeping with stale chi every night. And if that happens, then how can you
expect your life to bring in more good fortune to come to you? So open that window and
never mind if dusts comes in! The great good fortune that you can have will far exceeds the
time you take to clean off the dust.

- See more at: http://www.fengshuitips.co.uk/home.htm#sthash.L6VkeOyo.dpuf