advance care planning tools
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© 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
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
Advance Care Planning (ACP)
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
Video Clip
The role of ACP in providing good comfort care: example of what happens when ACP
has not vs. has been done
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
How is ACP done in your facility?
Who is responsible for obtaining advance directives?
Advance Care Planning (ACP)
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
Advance Care Planning
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
Video Clip
The role of the interdisciplinary team in Advance Care Planning
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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:
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
Originally adapted from:
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
Documenting ACP in Your Facility
Originally adapted from:
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
National effort to implement
POLST/MOLST
http://www.ohsu.edu/polst/
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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.
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
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