ADVANCE CARE PLANNING W HA T W HY W HEN & HO W
WHAT IS ADVANCE CARE PLANNING Ad va nc e Ca re Pla nning : Fac ilitate d c o nve rsatio ns be twe e n patie nts, lo ve d • o ne s and he althc are ag e nts Re fle c ts o n g o als, value s and be lie fs • Disc usse s tho se g o als, value s and be lie fs in re latio n • to po ssible he althc are c ho ic e s Co mmunic ate s the plan fo r c ho ic e s to o the rs • Ho no ring Cho ic e s M N •
WHAT ADVANCE CARE PLANNING IS NOT • I t is no t a c ode status c o nve rsa tio n- c o de sta tus will b e a na tura l b y pro duc t o f a n Adva nc e Ca re Pla nning Co nve rsa tio n • I t is no t yo ur re gulatory c are plan - pa tie nt c e nte re d g o a ls o f c a re will b e a na tura l b y pro duc t o f a n Adva nc e Ca re Pla nning Co nversa tio n • I t is no t a doc ume nt - a DPOA/ L iving Will/ Po rta ble Orde rs ma y b e a na tura l b y pro duc t o f a n Adva nc e Ca re Pla nning Co nversa tio n a nd AL L Adva nc e Ca re Pla nning c o nve rsa tio ns must b e do c ume nte d in a n e a sily a c c e ssib le lo c a tio n fo r AL L fa c ility sta ff to re view.
WHY DO ADVANCE CARE PLANNING AT YOUR FACILITY • Re g ula to ry Re q uire me nts Patie nt Se lf De te r minatio n A c t 1991 • C O P fo r L T C -§483.10(c )(6), (c )(8), (g ) (12)-”A dvanc e C ar e planning ” is a pr o c e ss o f • c o mmunic atio n be twe en individuals and the ir he althc ar e ag e nts to unde r stand, r e fle c t o n, disc uss, and plan fo r futur e he althc ar e de c isio ns fo r a time whe n individuals ar e no t able to make the ir o wn he althc ar e de c isio ns . • Co mp re he nsive Pa tie nt Ce nte re d Ca re Pla ns A dvanc e C ar e planning is an inte g r al aspe c t o f the fac ility's c o mpr e he nsive c ar e • planning pr o c e ss and assur e s a r e -e valuatio n o f the r e side nt’s de sir e s o n a r o utine basis and whe n the r e is a sig nific ant c hang e in the r e side nt’s c o ndition. A sse ssment-the r e side nt must r e c e ive a c o mpr e he nsive asse ssment to pr o vide • dir e c tio n fo r the de ve lo pme nt o f the r e side nt’s c ar e plan to addr e ss the c ho ic e s and pr e fe r e nc es o f the r e side nt who is ne ar ing e nd o f life … initia te disc ussio ns/ co nsider a tio ns re g a r ding a dva nce c a re pla nning a nd re side nt c ho ice s to c la rify g o a ls a nd pre fe re nce re g arding tre a tment inc luding pa in ma na g ement a nd ding ho spita liza tio n . sympto m c o ntro l, tre a tment o f a c ute illne ss, a nd c ho ic e s re g a r Ca re Pla n: the c a re pla n must b e b a se d upo n the re side nt a sse ssme nt, c ho ic e s • a nd a dv a nc e dire c tiv e s, if a ny. • PT AC
WHY DO ADVANCE CARE PLANNING AT YOUR FACILITY Ge ne ra l p o pula tion: 2013 a na lysis o f a He a lth Style s • Surve y(natio nal survey se nt o ut fro m a ll 7 c e nsus b ure a us) fo und 26.3% 18 & o ld e r o f the re sp o nd e nts ha d a n Ad vanc e Dire c tive -of tho se with a n AD, 51.2% we re 65 o r o ld e r a nd o nly 11.8% o f tho se 18-34 ha d a n AD Whe n inte r vie wed w/ in 30 d a ys o f d e a th, o nly 31% o f p a tients a nd • 52% o f c a re give rs b elieved the p a tie nt ha d le ss tha n o ne ye a r to live. 80% think ACP is imp o r tant, o nly 25% ha ve re c ord ed the ir wishe s • < 50% ha ve ta lke d to the ir fa mily a b o ut the ir wishes • Only 11.9% p re fe rre d life -prolo nging c a re • Re fe re nc e s 1,2,3,4
WHY DO ADVANCE CARE PLANNING AT YOUR FACILITY 90% think talking to the ir d o c to r is impo rtant, o nly • 20% have ac tually d o ne so . 89% o f HCP think ACP c o nve rsatio ns are impo rtant • and 75% o f d o c to rs say its the ir re spo nsibility. Physic ians te nd to o ve re stimate survival, e ve n in • patie nts with kno wn te rminal c o nd itio ns. Ove r 50% o f d o c to rs re po rt the y are • unc o mfo rtable having the se c o nve rsatio ns Referenc es 1,2,3,4
WHY DO ADVANCE CARE PLANNING AT YOUR FACILITY Ag re e me nt be twe e n E OL pre fe re nc e s and the • E MR d o c ume ntatio n was 30.2% Whe n d o c ume ntatio n e xists, c linic ians o fte n d o n’ t • no tic e it Wishe s c apture d in le g al d o c ume nts are no t • always translate d into ac tio nable me d ic al o rd e rs, le aving HCP unc e rtain abut what ac tio ns to take in a me d ic al c risis Referenc es 1,2,3,4
WHY DO ADVANCE CARE PLANNING AT YOUR FACILITY
WHY DO ADVANCE CARE PLANNING AT YOUR FACILITY “ F o r c e rta in pa tie nt po pula tio ns, ACP is pa rtic ula rly impo rta nt. T he risk o f ha rm is e le va te d a nd mo re a ppa re nt in pa tie nts with se rio us illne ss o r o lde r a g e . As a c o nse q ue nc e o f the ir c o nditio ns, suc h pa tie nts ha ve a n inc re a se d risk o f de a th, a nd ma y a lso ha ve a n inc re a se d risk o f po te ntia lly ha rmful e ve nts suc h a s ho spita liza tio ns, lo ss o f c a pa c ity, lo ss o f inde pe nde nc e , o r lo ss o f ide ntity. …fa ilure to c o nduc t a ppro pria te ACP c o uld b e c o nside re d ne g lig e nt, re sulting in unne c e ssa ry suffe ring a nd ha rm.” (fo r b o th re side nts a nd fa milie s) Alle rg y Ana lo g y: “ Pro viding c a re w/ o e ng a g ing in c o nve rsa tio ns a b o ut E OL c a re wishe s & de live ring c a re inc o nsiste nt w/ pa tie nts’ sta te d wishe s we re o n pa r with me dic a l e rro rs.” (Dr . L a c hla n F o r r o w , Dir e c to r o f Ethic s a nd Pa llia tiv e Ca r e , Be th Isr a e l De a c o ne ss Me d ic a l Ce nte r ) Re fe r e nc e 4
WHEN TO DO ADVANCE CARE PLANNING AT YOUR FACILITY • On Ad missio n, with e ve ry pe rso n that c o me s into yo ur fac ility • No rma lize this pro c e ss • Se t e xpe c ta tio ns with re side nts/ fa milie s • Ma ke it pa rt o f yo ur a dmissio ns ro utine • Chang e In Co nd itio n • Re turn fro m ho spital • Re sid e nt/ family vo ic e c o nc e rns fo r what is happe ning • Annually
SCENARIO 96 y/ o fe ma le with a pa st me dic a l histo ry o f: de me ntia , ma c ula r de g e ne ra tio n, sync o pe , G E RD a nd a rthritis. Re side s a t a nursing fa c ility fo r the la st ye a r a fte r tra nsitio ning fro m a n a ssiste d liv ing fo llo wing a fra c ture . She is a le rt- no inc a pa c ity no te d. So n is inv o lve d in he r c a re . He no te s tha t he r me nta l sta te is up a nd do wn, b ut she wa s re c e ntly a b le to pla y a b o a rd g a me a nd wa s fa irly c o nv e rsa nt. Co de Sta tus o n a dmit is “ no c o de ” a nd ha s b e e n tha t fo r q uite so me time prio r to a dmissio n. T he re ha ve b e e n no c o nv e rsa tio ns re : g o a ls o f c a re o the r tha n c o de sta tus disc ussio n. Re side nt fa lls o ut o f b e d a nd e L T C ha s b e e n c o nta c te d. Nurse re po rts tha t re side nt ha s b e e n de c lining a nd ha ving multiple fa lls la te ly. She susta ine d a skin te a r, a b ra sio n/ he ma to ma to fo re he a d a nd no se b le e d. She is typic a lly mo re re spo nsiv e tha n she is a t the time o f the c a ll. Due to c ha ng e in a lte re d me nta l sta tus a nd no prio r g o a ls o f c a re c o nv e rsa tio ns, she is se nt to E D v ia a mb ula nc e . In the E R, re side nt ha s kne e pa in a nd is so mno le nt. Physic ia n spe a ks to so n who wa nts to “ limit te sting to o nly e me rg e ntly ne c e ssa ry te sts.” He is e a g e r to g e t he r b a c k to fa milia r se tting s a nd she is se nt b a c k to fa c ility. 1. Ho w wo uld ha v e a n ACP disc ussio n he lpe d in this situa tio n? 2. Ho w/ whe n wo uld yo u ha ve sta rte d this c o nv e rsa tio n?
HOW TO DO ADVANCE CARE PLANNING AT YOUR FACILITY • Ad vanc e Care Planning c o nve rsatio n are a spe c ific skill se t that c an be le arne d and d e ve lo pe d o ve r time . Ofte n, the se c o nve rsatio ns are he ld by a Palliative Care te am in a ho spital se tting . T his te am is mad e up o f spe c ially traine d : • Physic ia ns • Pro vide rs • Nurse s • So c ia l Wo rke rs • Cha pla ins • Pha rma c ists
HOW TO DO ADVANCE CARE PLANNING AT YOUR FACILITY Pre - re quisite : • Cha rt Re vie w- kno w the pa tie nts c o nditio n. Ha s the re b e e n pre vio us g o a ls o f c a re c o nve rsa tio n a t the ho spita l? • Do e s the pa tie nt ha ve c a pa c ity to ma ke c o mple x me dic a l de c isio ns? I f no t, who is the le g a l surro g a te de c isio n ma ke r (DPOA o r b y sta te sta tute ) • Are the re e xisting do c ume nts a nd wha t do the y sa y/ whe n we re the y do ne . T he y ma y a dd use ful insig ht • Co nside r using a va lue s c la rific a tio n wo rkshe e t to use during yo ur c o nve rsa tio n. I t wo uld b e c o mple te d prio r to the me e ting.
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