MiCMRC Educational Webinar

Advance Care Planning: Conversation Basics

August 8, 2018

MiCMRC Educational WebinarAdvance Care Planning: Conversation Basics

Expert Presenter:

Carol Robinson DNP, MS, BSN, RN, CHPN®Community Coordinator

Disclosures• There is no conflict of interest for anyone with the ability to

control content for this activity.• This webinar is available for CE credit until June 4, 2020 .• Participants who successfully view the entire live or recorded

webinar and complete the online CE process including required evaluation with email address will earn 1.0 contact hours.

• This continuing nursing education activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91) ONA # 21652

Instructions for Obtaining Nursing, Social Work, and CCMC CE CreditTo receive Nursing, CCMC, or Social Work 1.0 continuing education contact hour for “Advance Care Planning: Conversation Basics” for Today’s Live Webinar 8/8/018 2:00 – 3:00 PM

• Attend the entire webinar

• Go to the Michigan Care Management Resource Center web site http://micmrc.org/webinars

• On the micmrc web site webinar page, locate the “Advance Care Planning: Conversation Basics” webinar information – Click the link titled To Request CE Credit Click Here– Complete the brief form, include your e-mail address, click submit

• This will generate an email message to you containing a link to complete the CE request and required evaluation form

• Follow instructions in the e-mail: Complete the evaluation and submit. This step generates an email to you containing the CE certificate

*Note: This webinar will be recorded. CE for viewing the recorded webinar will be available on http://micmrc.org/webinars soon.

For technical assistance please e-mail: micmrc-requests@med.umich.edu

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Advance Care Planning: Conversation Basics

Carol Robinson DNP, MS, BSN, RN, CHPN®

Community Coordinator

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Learning Objectives

1. Describe basic skills for Advance Care Planning (ACP) facilitation

2. Explain how to initiate ACP conversations

3. Explore the meaning of living well

4. Explain the role of the Patient Advocate

5. Describe how to complete a clear AD

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Making Choices Michigan• Community-based, 501 (c)(3); wholly-owned subsidiary

of Great Lakes Health Connect

• Goal: Move the ACP conversation from the healthcare environment to the community-at-large

• Vision: foster a community culture where it is acceptable to talk about health care choices, including end of life, and to respect and honor those choices.

• Mission: encourage and facilitate advance healthcare planning by the people of Michigan.

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Definitions

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Advance Directive documents are only

as good as the conversations and the

process that goes into them.

Advance Care Planning (ACP):

A conversation, a process, a document, or all three?

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Durable Power of Attorney (DPOA)

• Written document in which youappoint a trusted person to act on your behalf, continuing the relationship beyond your incapacity.

• Includes decisions such as financial and legal affairs.

Legal dictionary (2014). http://legal-dictionary.thefreedictionary.com/Durable+power+of+attorney

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• The person YOU choose to share your medical decisions for you when you are unable to speak for yourself.

• The Patient Advocate must accept the role and sign the patient advocate role acceptance form!

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Durable Power of Attorney for Healthcare (DPOAH)

orPatient Advocate

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Advance Directive versus

Living Will

Advance Directive: • Appoints your Patient Advocate (PA)• Gives the PA the right to participate in discussions

about your care and ensures your wishes are followed• The form is a legal “stand alone” document in MichiganLiving Will: • Gives your medical instruction (goals of care/treatment

preferences) to your Patient Advocate• The GIFT you give your advocate!• It is not a required legal document in Michigan• It does not “stand alone” in Michigan

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Respecting Choices® Model

First Steps®

Healthy Adults in community-

MCM

Topics:Designate Patient

AdvocateClarify values

Document in AD

Next Steps®

Chronic or Life-limiting disease with

complications

Triggered at diagnosis. Focused on care & tx

specific to disease

Last Steps®

Life expectancy < 12 months

Topics:DNR,

hydration/nutrition. Complete MI-POST

Hammes, B. J., & Briggs, L. (2011)

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Barriers to ACP Conversations

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ACP Myths• Only “old”, frail or sick people need

an Advance Directive (AD)• The conversation will be “depressing”• “My doctor/family already knows

what I want.” • An AD is treated the same as a DNR

• “You will no longer receive treatment.”

• The ACP process is “one and done.”• Insurance companies want you to go

through ACP to save them money.• Healthcare providers understand

ACP• A DNR tattoo is as good as an

Advance Directive

Holt, G. E., Sarmento, B., Kett, D., & Goodman, K. W. (2017)

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Systemic Barriers

• Fragmented healthcare delivery system

• Leads to multiple ADs!

• Inopportune timing in the midst of crisis

• Inadequate structural support for ACP

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Facilitator Qualities

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Facilitator qualities…

• Desire to be a facilitator

• Able to provide a welcoming, open environment

• Be comfortable with silence ~ for at least 20-30 seconds!

• Willing to “trust the process”

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Therapeutic listening skills

• Be calm• speak slowly, clearly

and at an appropriate volume

• 80% of communication is non-verbal. Relax, maintain eye contact and have an open posture.

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Listening skills (con’t)

• Listening: you have two ears and one mouth for a reason

• Control your facial and body responses to surprising comments

• Don’t change the subject

• Encourage reminiscing

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Communication:Methods & Strategies

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Be prepared!• Information on who you are meeting (name,

approximate age, accompanying participants)

• Correct time/date/location (maps are our friends!)

• Schedule for 90 minutes (more if several people plan on completing an AD)

• Script(s)• Note pad & pen ~ including for the

participant(s)• Educational materials

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Be prepared (con’t)

• Familiarize yourself, in advance, with the Advance Directive and associated documents

https://makingchoicesmichigan.org/documents/

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Suspend your assumptions…

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Method: Set the stage…

• Choose a quiet spot• Good lighting• Turn off/silence all

devices• Water/beverages• Have a table nearby• Comfortable seating

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Set the tone… • Introductions, all

around!• Inform: you will be

asking questions to help them think about what matters most

• Explain that you will take notes

• Encourage them to ask for any clarifications ~ this is a 2-way conversation

• Option to complete the AD is at the end of the conversation

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Respecting the voice of the patient……

“No decision about me, without me.”

National Patient Safety Foundation (2008) Coulter, A., & Collins, A. (2011)

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Strategy: Frame the conversation1. Talk about what matters most to live well

2. Select/confirm your Patient Advocate(s)

3. Complete your Advance Directive

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Basic Conversation Skills:Introductory Phrases

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Understand and manage expectations• What made you decide to come to the

appointment today?• What do you hope to accomplish?• Are there pressing concerns or questions

you have about our meeting?• Tell me about your timeline. How long do

you expect to be here today?

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Explore “Living Well”

• Discuss• What is important to you to live life well?

• Health status, relationships, financial matters, independence, trajectory of previous/current relationships?

• What gives your life meaning?• What role do relationships play in your life?• Who, or what, is your source of hope and strength?

• From a cultural perspective, what would you want your healthcare team to know?

• Who makes the important decisions in your family?• What do you think about quality versus quantity of

life? What does your family think?

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“Who is your Patient Advocate?”or alternatively:

“Who will speak for you if you cannot speak for yourself?”

• Acclimates the person to ACP language (Patient Advocate, or Durable Power of Attorney for Healthcare [DPOAH])

• Most people can think of someone they trust to serve in the Patient Advocate role

• Changes the language from a legal transaction (“Do you have an AD?”) to one of relationship (“Who do you trust?”)

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If the person responds, “YES, I have a patient advocate”

“Have you had a meaningful conversation with your advocate(s) about what matters most to you to live life well?”

• Living life well is the crux of the conversation.

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Further…..“Have you formally (legally) documented your Advocate choice(s) in an Advance Directive?”

• Can your Advocate make hard decisions in stressful, emotional situations?

• Will your Advocate follow your wishes, even if he/she does not agree with them?

• Your Advocate(s) must accept the role in writing before the healthcare team can accept directions for care

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If the person responds, “No, I don’t have an Advocate”“Can you think of someone you trust who could do this for you?”

• Your advocate must be 18 or older• Your advocate does not have to be a

family member• Your advocate must be available ~

meaning they must be accessible by phone. Geography is not as big of an issue in the age of mobile phones.

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“Solo elders”Some people do not have family or friends who could serve in the Patient Advocate role. Think about the following potential options:• Trusted neighbor• Faith or belief group member• Club member• Some resident service coordinators are

willing to act as an advocate

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Documentation:Create your Advance Directive

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Creating a clear Advance Directive document• Choose your Advance Directive

document (examples)• Making Choices Michigan• MDHHS Patient Advocate

Designation• Five Wishes• DPOAH from attorney

• Technicalities: “if it’s not completed correctly, it won’t necessarily work”

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Patient Advocate Designation• The main purpose of

an AD is to name the advocate(s)!

• List them in your order of preference

• It is not a “consensus” scenario, nor a popularity contest!

• Make sure there is a reliable phone number

• Note: the Patient Advocate signature(s) do not need to be witnessed.

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Signed, Sealed, Delivered…It’s YOURS!

• Boxed information at the top is the “express permission” statutory language

• Read the witness requirements carefully before allowing signatures!

• Only the signature of the person creating the directive must be witnessed

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Treatment Preferences or(Living Will)~ optional section• The written preferences

for care are the “Living Will” component of an Advance Directive.

• The preferences are the “gift” you give your Patient Advocate(s)

• The preferences help your Advocate(s) and healthcare team follow your wishes for care.

• Appropriate for well adults and those with stable chronic illness.

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AD Storage & Retrieval“It doesn’t do you any good if no

one knows where to find it.”

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Storage and Retrieval“Where is your directive stored?”• Must be easily accessible

~ no safe deposit box!!• Copies are considered

legal• Advocates need a copy• Give to PCP and

preferred health care system

• Consider uploading to Great Lakes Health Connect Health Information Exchange

www.gl-hc.org/patient-care-documents/

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Conversation Toolsfor the lay public

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• Conversation Project Starter Kit• https://theconversationproject.org/wp-

content/uploads/2017/02/ConversationProject-ConvoStarterKit-English.pdf

• Death over Dinner• https://deathoverdinner.org/

• Engage with Grace: the One Slide Project• http://engagewithgrace.org/

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engagewithgrace.org The One Slide Project

1. On a scale of 1 to 5, where do you fall on this continuum?

2. If there were a choice, would you prefer to die at home, or in a hospital?3. Could a loved one correctly describe how you’d like to be treated in the

case of a terminal illness?4. Is there someone you trust whom you’ve appointed to advocate on your

behalf when the time is near?5. Have you completed any of the following: written a living will, appointed

a healthcare power of attorney, or completed an advanced directive?

Can You and Your Loved Ones Answer These Questions?

1 2 3 4 5

Don't give up on me no matter what, try any proven and unproven intervention possible

Let me die without medical intervention

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Further ACP Resources

Making Choices Michiganwww.makingchoicesmichigan.org

ACP Michiganhttps://www.acpmich.org/

Respecting Choices®: Person-Centered Carehttps://respectingchoices.org/

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• Communication is complex• The ultimate objective is the person’s

best interest• Individuals and their

families/advocate(s) must be involved in communication

• Your job? Promote communication among individuals, families and healthcare team members

Summary ~It’s about the conversation!

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ResourcesBack, A. L., Anderson, W. G., Bunch, L., Marr, L. A., Wallace, J. A., Yang, H. B., & Arnold, R. M. (2008, October 1). Communication about cancer near the end of life. Cancer, 1897-1910. doi:10.1002/cncr.23653

Coulter, A., & Collins, A. (2011). Making shared decision-making a reality: No decision about me, without me. In The King's Fund. Retrieved from https://www.kingsfund.org.uk/sites/default/files/Making-shared-decision-making-a-reality-paper-Angela-Coulter-Alf-Collins-July-2011_0.pdf

Hammes, B. J., & Briggs, L. (2011). Respective Choices® Gundersen Health System Advance care planning: Facilitator’s manual (3rd ed). Gundersen Lutheran Medical Foundation.

Hickman, R. L., Daly, B. J., & Lee, E. (2012). Decisional conflict and regret: Consequences of surrogate decision making for the chronically critically ill. Applied Nursing Research, 25, 271275.doi:10.1016/j.apnr.2011.03.003

Holt, G. E., Sarmento, B., Kett, D., & Goodman, K. W. An unconscious patient with a DNR tattoo [Letter to the editor]. The New England Journal of Medicine, 377(22), 2192-2193. doi:10.1056/NEJMc1713344

McPherson, A. & Parikh, R.B. (2017). Most people want to die at home, but many land in hospitals getting unwanted care. Washington Post. Retrieved from https://www.washingtonpost.com/national/health-science/most-people-want-to-die-at-home-but-many-land-in-hospitals-getting-unwanted-care/2017/12/08/534dd652-ba74-11e7-a908-a3470754bbb9_story.html?utm_term=.57bff557cfb1

Mealer, M., & Moss, M. (2016). Moral distress in ICU nurses [Electronic version]. Intensive Care Medicine, 42, 1615-1617. doi:10.1007/s00134-016-4441-1

National Patient Safety Foundation (2008). National agenda for action: Patients and families in patient safety. “Nothing about me, without me.” Retrieved from www.npsf.org

Rao, J. K., Anderson, L. A., Lin, F., & Laux, J. P. (2014). Completion of advance directives among U.S. consumers. American Journal of Preventive Medicine, 46, 1-13. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540332/pdf/nihms714216.pdf, doi:10.1016/j.amepre.2013.09.008

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