Anna Rahman, PhD, MSW
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
The development and evaluation of the INTERACT quality improvement program and Curriculum are supported by grants from the Retirement Research Foundation and The Commonwealth Fund
INTERACT Curriculum Session 8
Doctoral Associate, Miami University, Dept. of Sociology &
Gerontology, Oxford, Ohio
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INTERACT Curriculum Session 8
Teleconference Instructions
Call in Number 1-888-808-6959
Conference Code 3588988 #To un-mute your line to ask questions:
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Overview of the INTERACT Program and Curriculum
Welcome and Introductions
This session is designed for the entire interdisciplinary team, including the:
• Project champion and co-champion• DON, key RNs, LPNs, and CNAs• Medical director, primary care MDs, and NPs/PAs• Social workers• Administrators
ADVANCE CARE PLANNINGPart I: The Institutional Perspective
Anna Rahman, PhD, MSW is a doctoral associate at Miami University, Scripps Gerontology Center. Her work focuses on helping nursing homes implement evidence-based practices to improve care and quality of life for residents.
ADVANCE CARE PLANNINGPart I: The Institutional Perspective
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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
ADVANCE CARE PLANNINGPart I: The Institutional Perspective
The role of the interdisciplinary team in Advance Care Planning (ACP)
How to discuss ACP with residents and families Identifying residents who may benefit from comfort or palliative care Examples of comfort care measures Resources for discussing ACP and providing comfort and palliative
What This Session Will Cover
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
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
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
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
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Advance Care Planning (ACP)
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 CARE PLANNINGPart 2: The Individual Perspective
Advance Care Planning
The Role of the Interdisciplinary Team (1)
Medical care providers (MD, NP, PA) are responsible for discussing risks and benefits of various treatments and writing orders consistent with preferences
But, ACP is a team responsibility
Good decisions that honor resident preferences must be made with a health care team the resident and their decision makers trust
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Advance Care PlanningThe Role of the Interdisciplinary Team (2)
Social work staff should provide residents and families with information about ACP and advance directives at the time of admission and participate in ongoing ACP discussions
Licensed nursing staff should be aware of any advance directives and participate in ongoing ACP discussions as appropriate with residents, families, and health care decision makers
CNAs should understand their resident’s goals for care, and may become involved in ACP discussions because they are in constant contact with residents and families
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Advance Care PlanningThe Role of the Interdisciplinary Team (3)
Clergy and consultant psychologists can play a critical role in working with residents and their health care decision makers who find ACP discussions difficult and distressing
Consultant pharmacists can be helpful in providing comfort and palliative care
Administrators should take a leadership role in making ACP and documentation of ACP discussions and advance directives a priority
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Advance Care Planning
When?
ACP should occur at some time shortly after admission
Decisions should be reviewed regularly and at times of acute changes in condition
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
ACP is especially important among residents at high risk of dying in the very near future
This tool provides examples of residents who are at such risk
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
ACP is especially important among residents at high risk of dying in the very near future
This tool provides examples of residents who are at such risk
ADVANCE CARE PLANNINGPart I: The Institutional Perspective
Advance Care Planning (ACP)
What is the Role of INTERACT Tools in ACP?
INTERACT Advance Care Planning Tools are intended to be helpful in: Communicating with residents, families, and
other health care decision makers Providing examples of comfort care measures
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
Explain comfort care “Comfort care helps people live as well as they can for as long as they can.”
Reassure “Comfort care can help you and your family make the most of the time you have
left.”
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Please wait while the video is showing
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
Comfort or palliative care, whether or not the resident is enrolled in a hospice program, should include standard orders that address: Nutrition and hydration Activity Monitoring in the least
disruptive way Hygiene Comfort and safety
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
Comfort or palliative care, whether or not the resident is enrolled in a hospice program, should include standard orders that address: Nutrition and hydration Activity Monitoring in the least
disruptive way Hygiene Comfort and safety
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
Comfort care orders should also anticipate symptoms that can cause distress and discomfort, such as: Shortness of breath,
dyspnea, and terminal “death rattle”
Pain Anorexia Anxiety Seizures
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 and End-of-Life Care
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Your facility’s project champion is responsible for coordinating INTERACT 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
Suggested implementation activities before the next session:– Take 10 minutes after the teleconference to discuss next steps for improving
advance care planning in your facility. – Plan an in-service that teaches staff how and when to use the INTERACT
ACP Tracking Form. – Begin to use the ACP Tracking Form on one unit and monitor outcomes for
a month or so. Make any changes necessary based on this evaluation and then implement the form facility-wide.
Implementation Activities Before the Next Session:
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
Un-mute the line: Press # 6Please re-mute your line after talking: Press * 6
Questions and suggestions on Session 8 can also be directed to Dr. Rahman by email at:
Please insert in the Subject Line: “Question about the INTERACT Curriculum”
For teleconference participants:Questions, Suggestions, Comments?
ADVANCE CARE PLANNINGPart I: The Institutional Perspective
Session 9
QI Review Tool Revisited
Champions DON Key RNs and LPNs Medical Director
The Next Session
The topic and participants are listed belowFor teleconference participants, check the date and time for the next session
ADVANCE CARE PLANNINGPart 2: The Individual Perspective
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 #8 Quiz and Evaluation
ADVANCE CARE PLANNINGPart 2: The Individual Perspective