Advance Care Planning

Promoting Inter-Professional Practice

Presented March 24, 2007

Presented by:

Jane Keleher, MSc OT Candidate

Philip Santiago. MSc OT Candidate

Kara Braun, Masters of Theological Studies Candidate

Nadia Alam, MD

Definition of ACP

process of recurring clinician-patient-family communication that includesdecisions related to life-extending treatments such as resuscitation and dialysis; quality of life issues such as symptom control; preferences for the setting of care such as hospice;spiritual and emotional issues as they help define medical decisions, relieve suffering, and provide meaning and dignity

Dr. J.S. Weiner

Early project development

Originally master’s research project with Dr. Heather Lambert

Emphasis on advance directive forms – legally used or not?

Literature search highlighted move from advance directive forms to advance care planning process

Development with Quipped

Concept became interprofessional

Process of communication rather than the advance directive forms

Move away from legal issues

Move toward emotional and spiritual issues

Addition of Kara and Nadia to team

Advisors

Christine Chapman, QUIPPED

Dr. Cori Schroder, Palliative Care

Dr. Margo Paterson, Chair OT

Research Questions:

Can students imagine ACP as an inter-professional practice informed by a broad spectrum of beliefs and values, individual and professional?Can inter-professional education provide a means by which students become more comfortable with ACP?  Does this make the process of ACP easier?Can ACP become a shared responsibility through which health care professionals are better able to appreciate the benefits of inter-professional practice?

Facilitators objectives

build a comfortable level of competency in our own understanding of ACP

build a comfortable level of competency in providing education to colleagues

Module objectives for participants to demonstrate

Increased awareness of the importance of ACP and what it entailsNew or expanded knowledge of the roles/responsibilities of various health care professionals in ACP, emphasizing communicationIncreased awareness of how personal belief systems can affect the process of ACPAppreciation of the importance of understanding and respecting the values and beliefs of patients.

The Workshop

March 24, 2007

8:30 am - 12:30 pm

To start things off…

Expectations for the day.

Barry Smith’s video legacy.

David Rieff’s article about his mom, Susan Sontag.

Brainstorming what ACP encompasses.

What is ACP?

ACP is a process of recurring clinician-patient family communication that includesdecisions related to life-extending treatments such as resuscitation and dialysis; quality of life issues such as symptom control; preferences for the setting of care such as hospice;spiritual and emotional issues as they help define medical decisions, relieve suffering, and provide meaning and dignity

Dr. J.S. Weiner

Historical perspective on ACP to current endeavours.

The challenges of ACP… including a little vignette: “The Untrained Clinician”.

“The Untrained Clinician”

Mr. C is a 73-year-old man with acute leukemia. During a hospitalization for pneumonia, his physician, Dr. S, wishes to broach the subject of advance directives.Dr. S: How are you doing today?Mr. C: OK, my breathing is a little better. But can you give me something to sleep?Dr. S: Sure, no problem. Anything else bothering you? Mr. C: No, that's it.Dr. S: Okay, well, I wanted to talk to you today about something called advance directives. Do you know what that is?Mr. C: I think so. I'm not sure.Dr. S: Well, it's like decisions you need to make for the future. Medical decisions. To tell us what you want us to do.Mr. C: I'm not sure what you mean.Dr. S: Well, if something happens we need to know what you want us to do medically.Mr. C: Like what?Dr. S: Like if your heart stops beating or you stop breathing, do you want us to put the tube in.Mr. C: (confused silence).

Experiential Exercises

Self-reflection through visualization: The Trunk in the Attic.

The case of a 19 y.o. boy, recent high school grad, involved in a car crash while driving under the influence of alcohol. – Aspects of the case touched on dealing with

distraught family, spiritual angst, the possibility of disability, and the potential for financial strain.

The Quality Quantity QuestionnaireRietjens et al.

In order to live a bit longer, I would clutch at any straw.If I would become seriously ill, I would accept every treatment that can prolong my life, whatever the side effects may be.If I would become seriously ill, I would always accept a hard-to-tolerate treatment, even if the chance of its prolonging my life was as little as 1%.If I would become seriously ill, I would probably manage to find the strength to continue.A moment might come in which I would say: “I have done my best, this is the limit.”If a life-prolonging treatment would prevent me from leading a normal life, then I would rather not have it.I can imagine some side effects being so bad that I would refuse the treatment, even if that meant a shorter life.If I had to endure 6 months of hard-to-tolerate treatment in order to live for an extra half year, then I would not be willing to get that treatment.

A Workshop to Teach Medical Students Communication Skills and Clinical Knowledge About End-of-Life Care

Torke et al.

Opening the end-of-life/ AD discussion– Ask permission to talk.– Ascertain the patient’s understanding of the disease.– Ask about the patient’s emotional state.– Introduce the topic.– May need to reassure patient that you are not raising these

issues because he/she is about to die.Assess pt preferences re: end-of-life care– Explain treatment options at the end of life.– Gain a deep understanding of patient preferences.

Torke et al. continued.

Critical steps to creating an AD– Identify pt preferences– Identify surrogate decision maker(s)– Plan to communicate with SDM re: preferences– Plan to communicate with health care providers re: preferences– Document preferences and SDMs

Supportive Closing– Emphasis on active and engaged supportive care of the pt– Arrange follow-up.

Living Well Interview QuestionsSchwartz et al.

Maintaining or fulfilling what activities/ experiences are most important for you to feel your life has qulaity or for you to live well? (What makes you happy?)What fears or worries do you have about your illness or medical care?If you have to choose between living longer and quality of life, how would you approach this balance?Are there any special events/ activities that you are looking forward to?What needs or services would you like to discuss?Do you want information about anything related to your present or future care?What sustains you when you face serious challenges in life?Do you have any religious or spiritual beliefs that are important to you?In what way do you feel you could make this time especially meaningful to you?What do you hope most for those closest to you?

Fitchett’s model of spiritual assessment

1. Beliefs & meanings: higher purpose, meaning of life.2. Authority & guidance: Individual/ group/ resource whom they trust.3. Experience & emotion: perception of events and circumstances.4. Fellowship: formal/informal community.5. Ritual & practice: significance in activities, traditions.6. Courage & growth: dealing with doubt, change and challenges.

7. Vocation & consequences: their calling.

Emotional and Cognitive Barriers

Weiner suggested that discussions around ACP often raise strong emtions (anxiety, frustration, anger, sadness, hopelessness).

If these emotions are not properly dealt with, they can become foci for subsequent negative behaviour.

Reframing Barriers to ACP

Cognition: People generally do not want to discuss issues related to death and dying.Consequence: Displacing anxiety onto the other (patient, family, your loved one), depriving them of an important opportunity to have input into their care.Reframing Task: Shift this generalization to consideration of what the particular patient needs:– What are your thoughts about your illness?– What is the hardest part for you?

Reframing Barriers to ACP

Cognition: I will take away hope if I bring up ACP

Consequence: This narrowly defines hope as ‘hope to not die,’ which then makes us feel hopeless and helpless.

Reframing Task: Redefine other kinds of hope we can offer.

Reframing Barriers to ACP

Cognition: If I cannot offer cure I have failed; if my services are not needed there is nothing for me to do.

Consequence: Possible to experience humiliation, shame or helplessness.

Reframing Task: Consider the differences between curing disease and healing suffering.– Examine your openness to assume roles other than curing

disease.

Appreciating Our Unique Functions in ACP

Mentor input: selected readings, personal experience/expertise.

Sharing circle: participant input and experience.

Results of the Workshop

Evaluation

Post-Module Questionnaire– 9 Likert scale questions– 6 open-ended questions

N = 20– 2 Physiotherapy, 2 Theology, 2 Medicine, 6

Nursing, 8 Occupational Therapy

Quantitative Results

ACP: What it entails– Increased general understanding of ACP

• 100% agreed or strongly agreed

– Increased appreciation of the importance of ACP

• 100% agreed or strongly agreed

Quantitative Results

Inter-professionalism in ACP– Increased understanding of one’s own

professional role/responsibility in ACP• 65% agreed or strongly agreed• 20% undecided• 15% disagreed or strongly disagreed

Quantitative Results

Inter-professionalism in ACP– Increased understanding of the

roles/responsibilities of other professionals in ACP

• 85% agreed or strongly agreed• 10% undecided• 5% strongly disagreed

Quantitative Results

Role of personal belief systems in ACP– Increased awareness of how one’s own values and beliefs

influence ACP• 95% agreed or strongly agreed

• 5% unresponsive

– Increased awareness of the importance of understanding and respecting the patient’s values and beliefs in ACP

• 100% agreed or strongly agreed

Qualitative Results

If you were to discuss ACP with a patient or a loved one, what would be some of the key components you would consider?– 3 main themes:

• Empowering the patient (70%)• What ACP entails (65%)• Personal belief systems (55%)

Qualitative Results

What do you perceive to be the benefits to an inter-professional approach to ACP?– 5 main themes:

• Synergistic team effort in ACP (50%)• Specialist role in ACP (40%)• Generalist role in ACP (10%)• Coordinated communication (5%)• Acknowledgment of patient affect (5%)

Qualitative Results

What do you perceive to be the challenges to an inter-professional approach to ACP?– 4 main themes:

• Coordinated communication (40%)• Time constraints (30%)• Specialist role in ACP (15%)• Lack of professional curriculum (10%)

Qualitative Results

What was the highlight of the module?– 2 main themes:

• Workshop design (90%)• What ACP entails (20%)

Qualitative Results

What did you enjoy least about the module?– 2 main themes:

• Too short (50%)• Workshop design (30%)

Significance of the study:

explores an area of practice not well documented in the literature on interprofessional education. lack of educational initiatives on advance care planningvaluable in the training of students and practitioners alike. invites exploration of future healthcare team members’ values and beliefspromotes awareness of the client’s vantage in ACP

Future applications

Deliver module as part of curriculum for healthcare and theology students

Deliver module to interprofessional teams in hospitals and long term care facilities

Adapt module for general public– Know end of life care wishes earlier– Normalize conversation around death and dying