advance care planning tools

© Florida Atlantic University 2011

ADVANCE CARE PLANNING TOOLSADVANCE CARE PLANNING TOOLS

Joseph Ouslander, MD Florida Atlantic University

Gerri Lamb, PhD, RN, FAAN Arizona State University

Laurie Herndon, GNP Mass Senior Care

Ruth Tappen, EdD, RN, FAAN Florida Atlantic University

Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence


ADVANCE CARE PLANNING TOOLS

Advance Care Planning (ACP)

What is it?

ACP is a process of communicating with residents and others who may be making health care decisions for them

The focus is on preferences for treatment in the event of changes in condition, and in particular at the end of life

Discussions include explanation of options, benefits, and risks





What are the Goals?

To honor resident preferences for care To document preferences clearly and

communicate them so they can be honored at the appropriate times in the facility as well as after discharge



An advance directive is a general term that describes legal documents expressing a person’s preferences for care (e.g. Living Will, Durable Power of Attorney for Health Care)

Specific orders should be written that can help make sure residents’ wishes documented in advance directives are followed, for example: Do Not Resuscitate (“DNR”) No Tube Feeding Do Not Hospitalize (“DNH”) unless necessary for comfort

Advance Directives



Video Clip

The role of ACP in providing good comfort care: example of what happens when ACP

has not vs. has been done



How is ACP done in your facility?

Who is responsible for obtaining advance directives?




What is the Role of ACP in the INTERACT Program?

Residents nearing the end-of-life are often transferred to the hospital

Many of these transfers result in increased discomfort, distress and complications

Comfort and/or palliative care can often be provided within the nursing home



What is the Role of INTERACT Tools in ACP?

The Advance Care Planning Tools can be helpful in: Educating staff Refining policies and procedures for ACP Communicating with residents, families, and other

health care decision makers Providing examples of comfort care measures



Advance Care Planning

When?

ACP should occur at some time shortly after admission

Decisions should be reviewed regularly and at times of acute changes in condition




Who? The MD is responsible for discussing risks

and benefits of various treatments and writing orders consistent with preferences

But, ACP is an interdisciplinary team responsibility

Good decisions that honor resident preferences must be made with a health care team the resident and their decision makers trust



Video Clip

The role of the interdisciplinary team in Advance Care Planning




How?

INTERACT ACP tools and other resources are helpful in educating staff and for policies and procedures

Use a systematic approach towards evaluating and refining your current ACP practices



Steps to Improve ACP in Your Facility

1. Assess the Current Situation a. Approaches currently used and people responsible

b. Percent of residents with documentation of initial discussions

c. Percent of residents with advance directives, living will, and a health care surrogate decision maker

2. Select ACP as an area for potential improvement based upon preliminary assessment

3. Review state laws and regulations on ACP

Originally adapted from:



4. Identify areas for improvement in processes and practices:a. Current policies and protocols

b. Actual practice related to ACP

c. Issues that have arisen related to ACP

d. Previous attempts to address need for improvement

5. Identify barriers and challenges to improvement and strategies to overcome them

6. Reinforce practices that are already optimal

7. Implement needed changes and re-evaluate

Steps to Improve ACP in Your Facility




Documenting ACP in Your Facility


ADVANCE CARE PLANNING TRACKING FORM

RESIDENT NAME:______________________________________________________

ADMISSION (within a few days of admission or readmission) (Select One) □ Resident and/or responsible party does NOT want to have this discussion□ Discussion about advance care planning held with (circle): resident surrogate (name) both

___________________________ _________________(Staff or health care provider name) (Title)

Signature: ____________________________ Date of Discussion: ______/_____/_____ Location of Advance Care Plan documentation (i.e., medical record, plan of care, progress

notes:Use Continuation Pages to document additional Advance Care Planning

reviews and discussions



This material was adapted from the Birmingham VA Safe Harbor Project in 2007

ACP is especially important among residents at high risk of dying in the near future

This tool provides examples of residents who are at such risk



National effort to implement

POLST/MOLST

http://www.ohsu.edu/polst/



Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.



Explain comfort care “Comfort care helps people live as well as they can for as long as they can.”

Reassure “Comfort care can help you and your family make the most of the time you have

left.”

Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.



Comfort or palliative care, whether or not the resident is enrolled in a hospice program, should include standard orders that address: Nutrition and hydration Activity Monitoring in the least

disruptive way Hygiene Comfort and safety




Comfort care orders should also anticipate symptoms that can cause distress and discomfort, such as: Shortness of breath,

dyspnea, and terminal “death rattle”

Pain Anorexia Anxiety Seizures




Caring Connections – downloadable educational information and forms from the National Hospice and Palliative Care Organization (www.caringinfo.org)

Coalition for Compassionate Care of California - Resources for both health care providers and for lay people who want to talk about advance care planning, including downloadable forms and factsheets. http://www.coalitionccc.org/advance-health-planning.php

Alzheimer’s Association - Comprehensive recommendations aimed at improving communication and care at end of life. http://www.alz.org/national/documents/brochure_DCPRphase3.pdf

Aging with Dignity - offers a document called “Five Wishes,” which makes ACP more user-friendly, valid in 40 states; downloadable for $5 (www.agingwithdignity.org/5wishes.html)

Examples of Resources for ACP

advance care planning tools

Documents