ADVANCE CARE PLANNING TOOLS

1. ADVANCE CARE PLANNING TOOLS Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNPMass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPHThe Carolinas Center for Medical Excellence

2. ADVANCE CARE PLANNING TOOLS What is it? Advance Care Planning (ACP) • 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

3. What are the Goals? Advance Care Planning (ACP) • 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

4. Advance Directives • 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

5. Video Clip The role of ACP in providing good comfort care: example of what happens when ACP has not vs. has been done

6. Advance Care Planning (ACP) How is ACP done in your facility? Who is responsible for obtaining advance directives?

7. 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

8. 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

9. When? Advance Care Planning • ACP should occur at some time shortly after admission • Decisions should be reviewed regularly and at times of acute changes in condition

10. 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

11. Video Clip The role of the interdisciplinary team in Advance Care Planning

12. How? Advance Care Planning • 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

13. Steps to Improve ACP in Your Facility Assess the Current Situation Approaches currently used and people responsible Percent of residents with documentation of initial discussions Percent of residents with advance directives, living will, and a health care surrogate decision maker Select ACP as an area for potential improvement based upon preliminary assessment Review state laws and regulations on ACP Originally adapted from:

14. Steps to Improve ACP in Your Facility Identify areas for improvement in processes and practices: Current policies and protocols Actual practice related to ACP Issues that have arisen related to ACP Previous attempts to address need for improvement Identify barriers and challenges to improvement and strategies to overcome them Reinforce practices that are already optimal Implement needed changes and re-evaluate Originally adapted from:

15. 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 Originally adapted from:

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

17. National effort to implement POLST/MOLST http://www.ohsu.edu/polst/

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

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

20. 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 .

21. 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

22. 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

23. Examples of Resources for ACP • 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)