Ruth Tappen, EdD, RN, FAAN Eminent Scholar and Professor Christine E. Lynn College of Nursing Florida Atlantic University ADVANCE CARE PLANNING Part I:

Ruth Tappen, EdD, RN, FAANEminent Scholar and Professor

Christine E. Lynn College of NursingFlorida Atlantic University

ADVANCE CARE PLANNINGPart I: The Institutional Perspective

The development and evaluation of the INTERACT II quality improvement program and Curriculum are supported by grants from the Retirement Research Foundation and the Commonwealth Fund

INTERACT II Curriculum Session 7

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Welcome and Introductions

This session is designed for the interdisciplinary team, including the:

• Project champion and co-champion• DON, key RNs, and LPNs• Medical director, primary care physicians, and

NPs/PAs• Social workers• Administrators


Ruth Tappen, EdD, RN, FAAN is an Eminent Scholar and Professor at the Christine E. Lynn College of Nursing Florida Atlantic University

[email protected]


The INTERACT Interdisciplinary Team

Laurie Herndon, GNP Mass Senior Care FoundationGerri Lamb, PhD, RN, FAAN Arizona State UniversityRuth Tappen, EdD, RN, FAAN Florida Atlantic UniversitySanya Diaz, MD Florida Atlantic UniversityJohn Schnelle, PhD Vanderbilt UniversitySandra Simmons, PhD Vanderbilt UniversityAnnie Rahman, MSW Miami UniversityJo Taylor, RN, MPH The Carolinas Center for Medical ExcellenceAlice Bonner, PhD, GNP Center for Medicare and Medicaid Services

In collaboration with participating nursing homes


Definition and goals of Advance Care Planning (ACP) and advance directives

Role of ACP in the INTERACT II program Process of obtaining advance directives – when and who Improving and documenting the use of ACP in your facility Resources on ACP

What This Session Will Cover



Advance Care Planning (ACP)

What is it?

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 should include explanation of options, benefits, and risks

Document these discussions and their results



What are the Goals?

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

Advance directive is a general term that refers to legal documents expressing a person’s preferences for care

The two most common advance directives are: Living will - documents the type and amount of

aggressive care the individual desires if terminally ill Durable power of attorney for health care -

allows people to identify others who can make future health care decisions in the event they cannot make their own


Advance Directives

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


Implementing Advance Directives

Physician (or Medical) Orders for Life-Sustaining Treatment (“POLST” or “MOLST”)

Section A: Resuscitation or DNR Section B: General level of medical intervention Section C: Antibiotic treatment Section D: Artificial nutrition or hydration Section E: Summary information


Categories of Orders on the Form


There is now a national effort to implement POLST/MOLST

http://www.ohsu.edu/polst/

http://www.ohsu.edu/polst/

Each state regulates the use of advance directives differently


Advance Directives

National Use of POLST


Advance Care Planning

When?

Many conditions in nursing home residents follow a chronic progressive course

ACP should begin early but discussions should be ongoing because decisions often change over time

Onset

Acute worsening/partial recoveries/gradual decline

Death

Typical Course of Chronic Progressive Illnesses



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

Hospitalized for the 4th time in 2 months for aspiration pneumonia related to end-stage Alzheimer’s disease

No advance directive was in the record Previous admissions included a week in the

ICU on a respirator and placement of a PEG tube

Transferred to hospice on the day of his 4th hospital admission

Sam - a 101 year old long-stay resident



Could some of these hospitalizations, intensive care, and PEG tube been avoided by better ACP?



When?

ACP should occur at some time shortly after admission

Decisions should be reviewed periodically and when an acute change in condition occurs

ADVANCED CARE PLANNING TOOLS



Who?

Physicians: responsible for discussing risks and benefits of various treatments and writing orders consistent with resident preferences

The interdisciplinary team:Good decisions that honor resident

preferences must be made with a health care team the resident and their decision makers trust


Please wait while the video is showing



How?

The next INTERACT II Curriculum session will discuss the use of INTERACT II ACP tools and other resources

Goal 6 - Advance Care Planning: Following admission and prior to completing or updating the plan of care, all NH residents will have the opportunity to discuss their goals for care including their preferences for advance care planning with an appropriate member of the healthcare team. Those preferences should be recorded in their medical record and used in the development of their plan of care.


http://www.nhqualitycampaign.org/star_index.aspx?controls=welcome

http://www.nhqualitycampaign.org/files/impguides/6_AdvanceCarePlanning_TAW_Guide.pdf

http://www.nhqualitycampaign.org/star_index.aspx?controls=welcome

Seven Steps to Improve ACP in Your Facility

1. Assess the Current Situation

a. Number and percent of residents with documentation of initial discussion

b. Number and percent of residents with advance directives, living will, and a health care surrogate decision maker

c. Approaches currently used and people responsible for implementation



Adapted from:




Adapted from:

2. Select ACP as an area for potential improvement based upon preliminary assessment

3. Review state laws and regulations and current information on ACP (see Resources)





Adapted from:

4. Identify areas for improvement in processes and practices including:

a. Current policies and protocols

b. Actual practice related to ACP

c. Issues that have arisen related to ACP

d. Previous attempts to address need for improvement




Adapted from:

5. Identify barriers and challenges to improvement and strategies to overcome them

6. Reinforce practices that are already optimal

7. Implement needed changes and re-evaluate


Documenting ACP in Your Facility



Adapted from:

Documenting ACP in Your Facility



Adapted from:

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

Caring Connections – downloadable educational information and forms (www.caringinfo.org/Home.htm - click on Advance Directives)

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)


Resources for ACP

Your facility’s project champion is responsible for coordinating INTERACT II implementation, and she or he may ask you to complete specific activities before the next teleconference or before you review the next session on-line.

For the Team as a Whole: Complete the assessment of advance care planning in your facility including

all of the aspects mentioned in this session: current rules and regulations in your state, current policies and practices in your facility, previous initiatives to improve advance care planning in your facility and any issues/challenges/barriers that need to be addressed.

Implementation Activities Before the Next Session:


Un-mute the line: Press # 6Please re-mute your line after talking: Press * 6

Questions and suggestions on Session 7 can be sent to me at [email protected] or also be directed to Dr. Ouslander by email at: [email protected]

Please insert in the Subject Line: “Question about the INTERACT II Curriculum”

For teleconference participants:Questions, Suggestions, Comments?


Session 8:

Advance Care Planning Part 2:The Perspective of the

Individual Resident

Champions DON Key RNs and

LPNs Lead CNAs

Medical Director

Key MDs, NPs/PAs

Social worker Administrator

The Next Session

The topic and participants are listed belowFor teleconference participants, check the date and time for the next session


Please complete the Post-Session Quiz and Evaluation If you take the Quiz and complete the Evaluation in a paper and

pencil format, please make sure your facility champion or co-champion gets a copy

If you are reviewing this session on-line, you can take the on-line Quiz and complete the evaluation on-line.

Post-Session #7 Quiz and Evaluation


Documents

Ruth Tappen, EdD, RN, FAAN Eminent Scholar and Professor Christine E. Lynn College of Nursing Florida Atlantic University ADVANCE CARE PLANNING Part I: