MiCMRC Educational Webinar Advance Care Planning: Conversation Basics August 8, 2018
MiCMRC Educational Webinar Advance Care Planning: Conversation Basics Expert Presenter: Carol Robinson DNP, MS, BSN, RN, CHPN Community Coordinator
Disclosures There is no conflict of interest for anyone with the ability to control content for this activity. This webinar is available for CE credit until June 4, 2020. Participants who successfully view the entire live or recorded webinar and complete the online CE process including required evaluation with email address will earn 1.0 contact hours. This continuing nursing education activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. (OBN-001-91) ONA # 21652
Instructions for Obtaining Nursing, Social Work, and CCMC CE Credit To receive Nursing, CCMC, or Social Work 1.0 continuing education contact hour for Advance Care Planning: Conversation Basics for Today s Live Webinar 8/8/018 2:00 3:00 PM Attend the entire webinar Go to the Michigan Care Management Resource Center web site http://micmrc.org/webinars On the micmrc web site webinar page, locate the Advance Care Planning: Conversation Basics webinar information Click the link titled To Request CE Credit Click Here Complete the brief form, include your e-mail address, click submit This will generate an email message to you containing a link to complete the CE request and required evaluation form Follow instructions in the e-mail: Complete the evaluation and submit. This step generates an email to you containing the CE certificate *Note: This webinar will be recorded. CE for viewing the recorded webinar will be available on http://micmrc.org/webinars soon. For technical assistance please e-mail: micmrc-requests@med.umich.edu
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8/8/2018 Advance Care Planning: Conversation Basics Carol Robinson DNP, MS, BSN, RN, CHPN Community Coordinator 8
8/8/2018 Learning Objectives 1. Describe basic skills for Advance Care Planning (ACP) facilitation 2. Explain how to initiate ACP conversations 3. Explore the meaning of living well 4. Explain the role of the Patient Advocate 5. Describe how to complete a clear AD 9
Making Choices Michigan 8/8/2018 Community-based, 501 (c)(3); wholly-owned subsidiary of Great Lakes Health Connect Goal: Move the ACP conversation from the healthcare environment to the community-at-large Vision: foster a community culture where it is acceptable to talk about health care choices, including end of life, and to respect and honor those choices. Mission: encourage and facilitate advance health care planning by the people of Michigan. 10
8/8/2018 Definitions 11
Advance Care Planning (ACP): 8/8/2018 A conversation, a process, a document, or all three? Advance Directive documents are only as good as the conversations and the process that goes into them. 12
13 8/8/2018 Durable Power of Attorney (DPOA) Written document in which you appoint a trusted person to act on your behalf, continuing the relationship beyond your incapacity. Includes decisions such as financial and legal affairs. Legal dictionary (2014). http://legal-dictionary.thefreedictionary.com/durable+power+of+attorney 13
14 8/8/2018 Durable Power of Attorney for Healthcare (DPOAH) or Patient Advocate The person YOU choose to share your medical decisions for you when you are unable to speak for yourself. The Patient Advocate must accept the role and sign the patient advocate role acceptance form! 14
8/8/2018 Advance Directive versus Living Will Advance Directive: Appoints your Patient Advocate (PA) Gives the PA the right to participate in discussions about your care and ensures your wishes are followed The form is a legal stand alone document in Michigan Living Will: Gives your medical instruction (goals of care/treatment preferences) to your Patient Advocate The GIFT you give your advocate! It is not a required legal document in Michigan It does not stand alone in Michigan 15
8/8/2018 Respecting Choices Model First Steps Next Steps Last Steps Healthy Adults in community- MCM Chronic or Life-limiting disease with complications Life expectancy < 12 months Topics: Designate Patient Advocate Clarify values Document in AD Triggered at diagnosis. Focused on care & tx specific to disease Topics: DNR, hydration/nutrition. Complete MI-POST Hammes, B. J., & Briggs, L. (2011) 16
8/8/2018 Barriers to ACP Conversations 17
8/8/2018 ACP Myths Only old, frail or sick people need an Advance Directive (AD) The conversation will be depressing My doctor/family already knows what I want. An AD is treated the same as a DNR You will no longer receive treatment. The ACP process is one and done. Insurance companies want you to go through ACP to save them money. Healthcare providers understand ACP A DNR tattoo is as good as an Advance Directive Holt, G. E., Sarmento, B., Kett, D., & Goodman, K. W. (2017) 18
8/8/2018 Systemic Barriers Fragmented healthcare delivery system Leads to multiple ADs! Inopportune timing in the midst of crisis Inadequate structural support for ACP 19
Facilitator Qualities 20
8/8/2018 Facilitator qualities Desire to be a facilitator Able to provide a welcoming, open environment Be comfortable with silence ~ for at least 20-30 seconds! Willing to trust the process 21
8/8/2018 Therapeutic listening skills Be calm speak slowly, clearly and at an appropriate volume 80% of communication is non-verbal. Relax, maintain eye contact and have an open posture. 22
8/8/2018 Listening skills (con t) Listening: you have two ears and one mouth for a reason Control your facial and body responses to surprising comments Don t change the subject Encourage reminiscing 23
Communication: Methods & Strategies 24
8/8/2018 Be prepared! Information on who you are meeting (name, approximate age, accompanying participants) Correct time/date/location (maps are our friends!) Schedule for 90 minutes (more if several people plan on completing an AD) Script(s) Note pad & pen ~ including for the participant(s) Educational materials 25
8/8/2018 Be prepared (con t) Familiarize yourself, in advance, with the Advance Directive and associated documents https://makingchoicesmichigan.org/documents/ 26
Suspend your assumptions 8/8/2018 27
8/8/2018 Method: Set the stage Choose a quiet spot Good lighting Turn off/silence all devices Water/beverages Have a table nearby Comfortable seating 28
8/8/2018 Set the tone Introductions, all around! Inform: you will be asking questions to help them think about what matters most Explain that you will take notes Encourage them to ask for any clarifications ~ this is a 2-way conversation Option to complete the AD is at the end of the conversation 29
Respecting the voice of the patient No decision about me, without me. National Patient Safety Foundation (2008) Coulter, A., & Collins, A. (2011) 30
8/8/2018 Strategy: Frame the conversation 1. Talk about what matters most to live well 2. Select/confirm your Patient Advocate(s) 3. Complete your Advance Directive 31
8/8/2018 Basic Conversation Skills: Introductory Phrases 32
Understand and manage expectations What made you decide to come to the appointment today? What do you hope to accomplish? Are there pressing concerns or questions you have about our meeting? Tell me about your timeline. How long do you expect to be here today? 33
8/8/2018 Explore Living Well Discuss What is important to you to live life well? Health status, relationships, financial matters, independence, trajectory of previous/current relationships? What gives your life meaning? What role do relationships play in your life? Who, or what, is your source of hope and strength? From a cultural perspective, what would you want your healthcare team to know? Who makes the important decisions in your family? What do you think about quality versus quantity of life? What does your family think? 34
Who is your Patient Advocate? or alternatively: Who will speak for you if you cannot speak for yourself? Acclimates the person to ACP language (Patient Advocate, or Durable Power of Attorney for Healthcare [DPOAH]) Most people can think of someone they trust to serve in the Patient Advocate role Changes the language from a legal transaction ( Do you have an AD? ) to one of relationship ( Who do you trust? ) 35
If the person responds, YES, I have a patient advocate Have you had a meaningful conversation with your advocate(s) about what matters most to you to live life well? Living life well is the crux of the conversation. 36
Further.. Have you formally (legally) documented your Advocate choice(s) in an Advance Directive? Can your Advocate make hard decisions in stressful, emotional situations? Will your Advocate follow your wishes, even if he/she does not agree with them? Your Advocate(s) must accept the role in writing before the healthcare team can accept directions for care 37
If the person responds, No, I don t have an Advocate Can you think of someone you trust who could do this for you? Your advocate must be 18 or older Your advocate does not have to be a family member Your advocate must be available ~ meaning they must be accessible by phone. Geography is not as big of an issue in the age of mobile phones. 38
Solo elders Some people do not have family or friends who could serve in the Patient Advocate role. Think about the following potential options: Trusted neighbor Faith or belief group member Club member Some resident service coordinators are willing to act as an advocate 39
Documentation: Create your Advance Directive 40
Creating a clear Advance Directive document Choose your Advance Directive document (examples) Making Choices Michigan MDHHS Patient Advocate Designation Five Wishes DPOAH from attorney Technicalities: if it s not completed correctly, it won t necessarily work 8/8/2018 41
Patient Advocate Designation The main purpose of an AD is to name the advocate(s)! List them in your order of preference It is not a consensus scenario, nor a popularity contest! Make sure there is a reliable phone number Note: the Patient Advocate signature(s) do not need to be witnessed. 42
Signed, Sealed, Delivered It s YOURS! Boxed information at the top is the express permission statutory language Read the witness requirements carefully before allowing signatures! Only the signature of the person creating the directive must be witnessed 43
Treatment Preferences or (Living Will)~ optional section The written preferences for care are the Living Will component of an Advance Directive. The preferences are the gift you give your Patient Advocate(s) The preferences help your Advocate(s) and healthcare team follow your wishes for care. Appropriate for well adults and those with stable chronic illness. 44
AD Storage & Retrieval It doesn t do you any good if no one knows where to find it. 45
Storage and Retrieval Where is your directive stored? Must be easily accessible ~ no safe deposit box!! Copies are considered legal Advocates need a copy Give to PCP and preferred health care system Consider uploading to Great Lakes Health Connect Health Information Exchange www.gl-hc.org/patient-care-documents/ 46
Conversation Tools for the lay public 47
Conversation Project Starter Kit https://theconversationproject.org/wp- content/uploads/2017/02/conversationproject- ConvoStarterKit-English.pdf Death over Dinner https://deathoverdinner.org/ Engage with Grace: the One Slide Project http://engagewithgrace.org/ 48
Can You and Your Loved Ones Answer These Questions? 1. On a scale of 1 to 5, where do you fall on this continuum? 1 2 3 4 5 Let me die without medical intervention Don't give up on me no matter what, try any proven and unproven intervention possible 2. If there were a choice, would you prefer to die at home, or in a hospital? 3. Could a loved one correctly describe how you d like to be treated in the case of a terminal illness? 4. Is there someone you trust whom you ve appointed to advocate on your behalf when the time is near? 5. Have you completed any of the following: written a living will, appointed a healthcare power of attorney, or completed an advanced directive? engagewithgrace.org The One Slide Project 49
Further ACP Resources Making Choices Michigan www.makingchoicesmichigan.org ACP Michigan https://www.acpmich.org/ Respecting Choices : Person-Centered Care https://respectingchoices.org/ 50
Summary ~ It s about the conversation! Communication is complex The ultimate objective is the person s best interest Individuals and their families/advocate(s) must be involved in communication Your job? Promote communication among individuals, families and healthcare team members 51
Resources Back, A. L., Anderson, W. G., Bunch, L., Marr, L. A., Wallace, J. A., Yang, H. B., & Arnold, R. M. (2008, October 1). Communication about cancer near the end of life. Cancer, 1897-1910. doi:10.1002/cncr.23653 Coulter, A., & Collins, A. (2011). Making shared decision-making a reality: No decision about me, without me. In The King's Fund. Retrieved from https://www.kingsfund.org.uk/sites/default/files/making-shared-decision-making-a-reality-paper- Angela-Coulter-Alf-Collins-July-2011_0.pdf Hammes, B. J., & Briggs, L. (2011). Respective Choices Gundersen Health System Advance care planning: Facilitator s manual (3 rd ed). Gundersen Lutheran Medical Foundation. Hickman, R. L., Daly, B. J., & Lee, E. (2012). Decisional conflict and regret: Consequences of surrogate decision making for the chronically critically ill. Applied Nursing Research, 25, 271275.doi:10.1016/j.apnr.2011.03.003 Holt, G. E., Sarmento, B., Kett, D., & Goodman, K. W. An unconscious patient with a DNR tattoo [Letter to the editor]. The New England Journal of Medicine, 377(22), 2192-2193. doi:10.1056/nejmc1713344 McPherson, A. & Parikh, R.B. (2017). Most people want to die at home, but many land in hospitals getting unwanted care. Washington Post. Retrieved from https://www.washingtonpost.com/national/health-science/most-people-want-to-die-at- home-but-many-land-in-hospitals-getting-unwanted-care/2017/12/08/534dd652-ba74-11e7-a908- a3470754bbb9_story.html?utm_term=.57bff557cfb1 Mealer, M., & Moss, M. (2016). Moral distress in ICU nurses [Electronic version]. Intensive Care Medicine, 42, 1615-1617. doi:10.1007/s00134-016-4441-1 National Patient Safety Foundation (2008). National agenda for action: Patients and families in patient safety. Nothing about me, without me. Retrieved from www.npsf.org Rao, J. K., Anderson, L. A., Lin, F., & Laux, J. P. (2014). Completion of advance directives among U.S. consumers. American Journal of Preventive Medicine, 46, 1-13. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4540332/pdf/nihms714216.pdf, doi:10.1016/j.amepre.2013.09.008 52
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