ADVANCE CARE PLANNING IN LONG TERM CARE · 2015-10-26 · Residents of long-term care facilities are at risk of serious medical illnesses and being unable to express choices when
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1 ADVANCE CARE PLANNING IN L ONG TERM CARE SHARON IVERSEN RN MCE Advance Care Planning: Goals of Care - Calgary Zone
SHARON IVERSEN RN MCE Advance Care Planning: Goals of Care - Calgary Zone
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Objectives for Today’s Presentation
• Discuss the importance of ACP in long term care settings
• Illustrate an advance care planning implementation framework as it relates to Calgary Zone long-term care settings
• Discuss strategies for embedding ACP best practices in LTC
Presenter
Presentation Notes
Residents of long-term care facilities are at risk of serious medical illnesses and being unable to express choices when difficult treatment decisions must be made. Advance care planning (ACP) allows residents to consider, make, and communicate their preferences for how medical decisions should be made if they are unable to participate in the decision-making process. This presentation describes the importance of ACP in long-term care facilities along with practical suggestions on how to develop and implement ACP programs.
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What is meant by a good death in LTC?
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Presenter
Presentation Notes
Many dying patients receive aggressive and often futile therapeutic interventions in the last weeks of life. ��Doctors often misunderstood patient preferences, especially when patients did not want high-technology, life-extending care. IN LTC dying in place is desired with palliative care services available It is their home and often lack capacity. UK The End of life care strategy (Department of Health, 2008) suggests: ‘Although every individual may have a different idea about what would, for them, constitute a “good death”, for many this would involve: • Being treated as an individual, with dignity and respect; • Being without pain and other symptoms; • Being in familiar surroundings; and • Being in the company of close family and/or friends.’ Alzheimer’s Society believes this is just as true for people with dementia as it is for people who have other health conditions. �
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Dementia/frailty trajectory
Presenter
Presentation Notes
Look at the trajectory for dementia. Health crises are likely with dementia- If they live long enough they experience swallowing problems, dehydration, poor immunity, inability to communicate and complete dependence. an average of 5-6 years of life after diagnosis of dementia These crises are not a result of poor care. Usually start seeing increasing health problems and more intervention.- some interventions are painful and or invasive It might be less difficult for families if they knew about these likely crises and knew about the options
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Presenter
Presentation Notes
What do you think this picture is about? The challenge is: Recognizing when a pt is coming towards the end of their road- Many dips in road and we may think we are there many times before the final time-road is slowly going downwards. It never comes back to where it started. What do you think these dips in the road would be? - UTI, hospitalization, fall, pneumonia, influenza If we could more accurately predict where people are on their road and knew what would change the length of the road, we could reduce possibly risky or painful interventions that do impact QOL. **The time to start palliative care is early on- identifying treatable issues to improve QOL while managing the disease with active treatment.
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at the time of a health care change/ crisis
how will health care decisions be made?
Presenter
Presentation Notes
Main questions include: should the resident be transferred? If so when to transfer? Use of medical interventions? Can they be treated and assessed in LTC? Should someone with advance dementia be hospitalized for acute pneumonia or urosepsis? Should antibiotics be used in all cases of infection? What about artificial nutrition if the person with dementia could not swallow or take fluids?� Should CPR be done if their breathing stops or heart stops? ‘ It was not a subject which was ever discussed as a family, so I still don’t know what his wishes would be. We looked for a living will, but there was nothing. The hardest thing is knowing what to do to make the decision on his behalf. We still, the three siblings, cannot all agree. So we can’t really put anything in place. The decisions will have to be made when the time comes.’ Daughter of a person with dementia
7 AHPCA Rural Road Show2012
in LTC what does an “ideal” advance care planning process look like
Presenter
Presentation Notes
For the patient/ for the staff/ for administration of records/ documents across HC sectors
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How great would this be? 1. Open recognition/communication of the residents
condition and prognosis Possible future scenarios, what options may exist
2. Having communication in place.. Putting the resident’s wishes and views at the forefront. NO tubes means NO tubes.
3. Staff have a clear process and direction about how to deal with deterioration in the health of the resident, family is aware and “prepared for these possibilities.”
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While we are dreaming…
All residents would share their wishes
with their agent and their family
reviewing contents of their personal
directive
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ACP / Goals of Care in LTC
Goals of Care Designation provides direction regarding: • specific health interventions
•transfer decisions •locations of care
•general intent or focus of care as established after consultation between the MD/ NP
and Resident /Family member
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Advance Care Planning: Goals of Care - Calgary Zone
The “Advance Care Planning: Goals of Care Designation (Adult)” (ACP: GCD) policy was launched across all sectors of the former Calgary Health Region on November 25, 2008. The Pediatric Policy was implemented in 2009.
Conversations Matter
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Advance Care Planning: Goals of Care - Calgary Zone
R Medical Care and Interventions including Resuscitation followed by ICU
M Medical Care and Interventions,
excluding Resuscitation
C Medical Care and Interventions, focused on Comfort
• Diagnosis • Prognosis • Anticipated
Outcomes • Wishes and Values • Life Support / Life
• Cure or control of condition with option for resuscitation
• Cure or control, no resuscitation
• Alleviate the symptoms
Process of arriving at a Goals of Care Order
Presenter
Presentation Notes
Features of our policy
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Personal Directive
Presenter
Presentation Notes
A Personal Directive is a legal document that directs healthcare providers in the case you are unable to make decisions or communicate your wishes about your health care. It may outline any treatments you may wish or refuse to accept, and may also name an agent(s)) who will speak for you. It is good practice to review the content of your PD once a year, or when your health condition changes, in order to be sure it is still what you want now and in the future. Your health-care provider may suggest changes to be considered. The personal directive only comes into effect if there is ever a time that you are unable to make decisions about your healthcare. It can be helpful in reducing conflict or distress and bringing comfort to those who you are close to because it clearly states who your healthcare decision maker is and can give direction on your wishes. Your wishes and values may change over time. This is normal. Your advance care planning, including your personal directive, can, and should be reviewed any time you have a change in your health circumstances or your wishes and values. If you would like more information about personal directives, you can contact the Office of the Public Guardian for assistance.
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• Are based on the Advance Care Planning discussions between the Resident and/or representative and the health care team
• Reflect the Resident’s values, wishes for health care and what is clinically appropriate
• May change over time in the face of changing health status
Goal of Care Designations
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GCD documented within 45 days of
admission to LTC (GCD)
R: Medical Care and Interventions, Including
Resuscitation
M: Medical Care and Interventions, Excluding Resuscitation
C: Medical Care and Interventions, Focused on Comfort
R M C
Goal of Care Designations POLICY
Presenter
Presentation Notes
goals of care designation guides your healthcare team to provide timely care that is both medically appropriate and reflects your personal values and wishes. There are three general approaches to care or Goals of Care: Resuscitative Care, Medical Care, and Comfort Care. The Goals of Care: Resuscitative care, medical care and comfort care can be divided into more specific sub-categories called Goals of Care Designations. These sub-categories provide your health care team with important information to help guide medical decisions about your treatment. Talk to your health care team about which goals of care designation best reflects your wishes and health circumstances.
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In Spring 2012, almost all charts reviewed had a (GCD).
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Distribution of GCD in
LTC DAL PAL
M
R
C
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The green sleeve holds
important documents
that outlines a person’s
goals for health care
Presenter
Presentation Notes
What is the purpose of the Green Sleeve? The Green Sleeve is a plastic pocket meant to house important documents that outline a person’s goals for health care. It is given to people cared for in Alberta Health Services – Calgary and area who have had discussions or completed documents that refer to decision-making about their current or future care. The information is intended to ensure that all healthcare providers in any setting have access to important decisions related to the patient’s goals of care and guidelines for direction of interventions that have been discussed with the patient. The Green Sleeve is to accompany the person as they transfer between care providers and sites and should be kept on or near the fridge when the patient is at home. What may the Green Sleeve contain? 1. Goals of Care Designation (GCD) order when one exists The GCD paper order format will be in the Green Sleeve except in areas that use electronic order entry. In areas using Sunrise Clinical Manager (Urban Acute Care Patient Care Information System) the order will be entered and viewed in electronic format. When a patient is transferred from an SCM order entry site to a non-SCM order entry site, the sending unit shall print the GCD order from SCM and place in the Green Sleeve and send with patient 2. Advance Care Planning Tracking Record The original of this document is kept in the Green Sleeve to allow care providers at each site access to and the ability to document the full record of conversations that have occurred over time. 3. Personal Directive (copy) if it exists.
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Advance Care Planning: Goals of Care - Calgary Zone
Tools
Presenter
Presentation Notes
Tracking record/ Order is written by physician or NP Describe the LTC Workflow process
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Review the designation: When there is a change
in health status • When there is a change
of treatment location • When new information
is available
The Process is Fluid
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Scenario - Bill Saunders 93 Bill has dementia, bladder ca with bone mets; he was recently hospitalization to treat uro sepsis/delirium requiring IV antibiotics Daughter Susan is distraught She has so many conflicting emotions Bill does not recognize Susan anymore. Prior to recent admission Bill’s GCD was...
Presenter
Presentation Notes
guilt sometimes wishing dad had died in hospital, relief that he improved with medications sadness that he seems to be slipping way…. In the event of further deterioration then comfort measures only Recent hospitalization for uro sepsis and delirium requiring In antibiotics
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Scenario - Bill Saunders 93
After his hospitalization Bill has stopped eating and drinking, and he is more and more bed bound.
PPS 40% The team ask for a meeting
with Susan, his agent
Presenter
Presentation Notes
what is the best way to take care of her father? Personal Directive and wishes are reviewed with Health Care Professionals and his daughter, Susan Conversation is documented on tracking record GCD changes to C1 focus is on comfort care /New GCD Order signed
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Scenario - Bill Saunders 93
One evening Bill’s pain becomes intractable; his rapid breathing, body language, vocalizations, facial expressions all indicate he is suffering intense pain, despite maximizing his pain medication options.
A decision to transfer Bill to Emergency Dept is made for SYMPTOM management only. EMS is called, green sleeve accompanies him to validate this.
Presenter
Presentation Notes
Breathing Negative vocalization Facial Expression Body Language Consolability
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For Bill.. how great is ACP? • Open recognition/communication of his condition
and prognosis • ACP is in place.. Putting Bill’s wishes and views at
the forefront. • Staff have a clear process and direction about how
to deal with deterioration in his health • Susan is aware and “prepared for EOL possibilities.” • A good death is possible.
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1. Engagement
ORGANIZATIONAL CONSIDERATIONS
• Who in your organization/unit/clinic needs to be aware of or
involved with ACP:GCD? • What is the best way to engage with these
individuals/groups? • Who outside or your organization/unit/clinic will be affected
by your integration of ACP:GCD? • How will you communicate with these individuals/groups? • What message will be presented to stakeholders? How will
this communication be maintained over time?
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1. Engagement
PATIENT/FAMILY/PUBLIC CONSIDERATIONS
• How will you engage your patients, families and/or the
public? • What are the key messages you want to present to your
patients? • How can this engagement be embedded into practice in
order to normalize ACP:GCD for patients/families?
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2. Education Minimum recommended standards
for staff education
• All clinicians and staff eLearning module • Unit clerks and other administrative staff who may be
engaged in the flow of documents in and/or out Administrative/Unit Clerk eLearning module
• all clinicians who have direct patient and/or family contact, to increase confidence and competence in engaging in ACP and GCD conversations. ACP Conversations Matter f2f education module
Presenter
Presentation Notes
who may be engaged in ACP:GCD conversations and/or processes should complete the ACP:GCD Other considerations: Identify champions within each role (ie: physicians, nurses, social workers, unit clerks) to support ongoing education efforts How will education be tracked and monitored ongoing? How will new staff and clinicians be oriented to ACP:GCD? Will clinicians and staff be required to ‘refresh’ their learning over time? Would it be helpful to engage the public with education to help normalize the process of ACP:GCD? What format might you use to educate the public? Who would be responsible for sustaining this education over time? What key messages are important for the public?
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3. System Infrastructure & Business Processes
• Who will order supplies and ensure they are stocked? • Where will they be kept? • Who is responsible for initiating a green sleeve for patients
who do not have one already? • Who is responsible for ensuring GCD orders are written? • How does the interdisciplinary team approach ACP
conversations with patients, and how is that communicated amongst the team?
• How and when are resources presented to patients?
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4. Continuous Quality Improvement (CQI)
• Identify key outcomes measures relevant to
organization/unit/clinic. • What do you want to know? • How will this information be used support the further
integration of the ACP:GCD policy? • How will this information be collected, analysed and reported?
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Advance Care Planning: Goals of Care: Calgary Zone
