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Pearls of Advanced Care Planning (ACP) by Mary Mueller, RN MSN APNP BC

Pearls of Advanced Care Planning (ACP) by Mary Mueller, RN MSN APNP BC. Objectives. The learner will be able to identify at least two key components of Advance Care Planning (ACP). The learner will be able to identify three possible goals of the process of ACP in long term care.

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Pearls of Advanced Care Planning (ACP) by Mary Mueller, RN MSN APNP BC

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  1. Pearls of Advanced Care Planning (ACP)by Mary Mueller, RN MSN APNP BC

  2. Objectives • The learner will be able to identify at least two key components of Advance Care Planning (ACP). • The learner will be able to identify three possible goals of the process of ACP in long term care. • The learner will be able to identify two vital elements of effective communication in the ACP process. • The learner will be able to apply key concepts of the ACP into day to day operations while caring for the resident and enhancing quality of care. • The learner will be able to identify at least two cultural, ethical or legal concepts that may impact effective ACP.

  3. Advanced Care Plan Process • Process of planning for the future • Directs the goals of care and establishes realistic boundaries • Assumes the right to participate in the planning of health care wishes • Personal journey based on cultural, personal and religious values, beliefs, and preferences • Trust building • Communication

  4. Components of Advanced Care Planning • Who: • Resident/Family Members/RPs • Primary Care Team (PCT) • Specialists, hospice • Spiritual leaders • How • Open ongoing honest comprehensive multidisciplinary communication • Commitment to timely accurate documentation • Establishing of appropriate goals of care • When (time, appropriateness) • Where (environment, settings)

  5. ACP as a Process of Communication • Develop process for open and ongoing interdisciplinary communication • It is not a finite process- ongoing • Encourage discussion of individual's values and preferences • Facilitate discussion of individual's understanding of the decision making process in advanced care planning based on life-to-death trajectory and the current physical and emotional state • Maintain open communication with the Primary Care Team throughout the entire process of ACP

  6. Timing for ACP Recommended times for advanced care planning discussions: • Initial assessment and/or admission • Review advance care planning status on routine assessments • When the individual has a change in condition • Change in condition that is treated in nursing facility • Change in condition associated with a hospitalization • Discussion after hospitalization,

  7. Goals of Care • To give the right care • To the right person • In the right place • At the right time • For the right reason

  8. A New Paradigm

  9. Longevity • “I want to live at all costs” • Looking for reversal of disease process • Looking for cure • Function at all costs

  10. Function • Maintain or increase function: • May give up longevity • Decrease Comfort • Must have a goal in mind • define function to be maintained • review living will

  11. Comfort • High touch—low tech • Pain management • Family • Support family tasks: reading, massage, Reiki hand positions • Proactive • In control of the death • Can orchestrate “the good death” • Hospice consideration

  12. Effective Advanced Care Planning Will yield: • Crisis avoidance • Adherence to wishes and values • Respect the right of individual to have opportunity to discuss life decisions • Opportunity to identify documentation needs to meet legal requirements (updated DPOAs, initiation of guardianships, timely activation of DPOAs, completion of Advanced Directives) • Ability to maintain ethical boundaries (futility, justice, negligence and malpractice)

  13. In Conclusion…. Evercare advocates the importance of Advance Care Planning Thank-you for your Time

  14. References • Aparanji K, Dharmarajan TS. Pause Before a Peg: A Feeding Tube may not be necessary in Every Candidate. JAMDA 2010;11(6): 453-455. • Associated Press. American are Treated, and Overtreated to Death June 28,2010. • Dunn, H. Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Care, and the Patient with a Life-Threatening Illness, 5th Ed • Quill, T, Arnold, R. Back, A. Discussing Treatment Preferences with Patients who want “everything”. Annals of Internal Medicine 2009; 151:345-349 • Volicer, L. Futility Discussion Revisited. JAMDA 2010; 11(6): 389-390 • Weissman, D. Decision Making at a time of Crisis Near the End of Life. Journal of America Medical Association 2004; 292(14):1738-1744 • http://www.cwag.org/legal/guardian%2Dsupport/ • http://www.dhs.wisconsin.gov/forms/AdvDirectives/ • http://evercarehealthplans.com/

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