Respecting Choices Key Components in Creating an Advance Care Planning Program Bernard Bud Hammes & Linda Briggs Copyright 2008-All Rights Reserved Foundation, Gundersen Inc. Lutheran Medical Key Conceptual Underpinnings: Advance Care Planning is an informed consent process in which barriers should be addressed before decisions can be made. Advance Care Planning must personally engage the individual who is planning through models of adult learning. 1
Key Conceptual Underpinnings: Advance Care Planning should use narrative and story to engage and to address barriers to decision-making. Advance Care Planning is more about the ethics of caring and relationships than about autonomy and rights. Key Conceptual Underpinnings Advance Care Planning needs to be hardwired into the routine of health care. Advance Care Planning systems need to achieve selected outcomes and be continuously measured and improved. 2
Elements of a Successful Advance Care Planning (ACP) Program Community Engagement ACP Facilitation Skills Training Systems to Wishes Honor Continuous Quality Improvement Community Engagement 3
Community Engagement Promotes advance care planning as a process, not an event Assistance talking to loved ones Consistent, common repetitive messages Frequent, community exposure Advance Care Planning is a process of: Understanding Reflection Discussion 4
Assistance talking with chosen surrogate, loved ones, and physicians Refocuses discussion of preferences away from autonomy toward personal relationships Prendergast, TJ.2001. Crit Care Med. 5
How can you guide your loved ones to make the best decisions for you? Professional Education 6
Professional Education ACP facilitator skills training Different interview skills for different discussions Appropriately staged timing of discussions ACP facilitation skills are identified, practiced, and reinforced 7
Advance care planning is not a one size fits all process Facilitators are trained to assist different groups of adults 8
Facilitators trained to assist: Healthy adults in basic ACP Adults with chronic, progressive illness understand options, benefits and burdens Adults whose death in the next 12 months would not be surprising make specific plans ACP Facilitator Training On-line modules for basic knowledge and skills. 8-hour in-class course for application and skill development. Social workers, RNs, chaplains, ministers/clergy, volunteers, attorneys. 9
Systems to Honor Wishes Systems Referrals to qualified team members Standardization of practices for entering, updating, and transferring written plans throughout health care system Actionable advance directives 10
ACP Team Approach Basic Role of Physicians 1. Initiate planning discussions/referrals 2. Review written plans that have been entered into the medical record. 3. Make plans more specific as patient s health condition changes 4. Convert plans into orders when appropriate 11
Basic Role of RN s 1. Assess need for information 2. Identify patient cues 3. Provide information on medical condition 4. Communicate patients choices, fears, concerns 5. Make referrals Written plans communicate person s goals, values, and beliefs Written plans accurately represent the facilitated ACP discussion 12
Continuous Quality Improvement Five Promises of an Effective Advance Care Planning Program Promise #1: We will initiate conversations Promise #2: We will provide assistance Promise #3: We will make sure plans are clear Promise #4: We will maintain and retrieve plans Promise #5: We will appropriately follow plans 13
Continuous Quality Improvement Organized approach to monitoring outcomes and making revisions Respecting Choices QI Toolkit Research 14
The La Crosse Advance Directive Study (LADS) Retrospective review of all deaths in La Crosse County from April 95-March 96. Of the 540 decedents eligible for the study: 85% had written AD s 96% of AD s were in medical record 98% of AD s written preferences were consistent with medical orders at the end-of-life. Arch Intern Med Feb. 23, 1998 From Advance Directives to Advance Care Planning Involvement of multiple professionals Organization and community effort Commitment to learning new skills and practices Cultural Change 15
The best approach to boost utilization is an initiative such as Respecting Choices combining grassroots education, a uniform system of documentation, and coordination among sites of care. M. Gillick, NEJM 2004 Advance Care Planning: A Means to a Better End one that is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients and families wishes, and reasonably consistent with clinical, cultural, and ethical standards. Institute of Medicine definition of a good death 16
www.respectingchoices.org 17