Transcript Respecting ChoicesTM - Sharing Your Wishes

Sharing Your Wishes
Advance Care Planning
Facilitator Course
GCC
September 2006
©Gundersen Lutheran Medical Foundation
©Gundersen Lutheran Medical Foundation
Advance Care Planning
Planning ahead for your last phase of life or for
an unexpected event, leaving you unable to
communicate.
©Gundersen Lutheran Medical Foundation
SHARING YOUR WISHES GRANT
This project is made possible by a grant from the Community Health Foundation of
Western and Central New York. The Community Health Foundation is a non-profit
private Foundation whose mission is to improve the health and healthcare of the
people of Western and Central New York.
• Awarded to the Genesee County Long Term Care Task Force.
• Initial 2 year initiative with potential for 3rd year.
• Six (6) surrounding counties involved.
• Targets frail elders and their caregivers.
©Gundersen Lutheran Medical Foundation
The goal of the project:
 Increase awareness in our community about Advance Care
Planning
 Using a holistic approach.
 Availability of care options and services
 Importance of health care decision making
 Stimulate communication
 Family
 Health care providers,
 Legal and spiritual advisors
 Strengthen our system
 Process to access long term care services is clear and accurate.
 To complete and effectively use advance care planning documents
©Gundersen Lutheran Medical Foundation
SHARING YOUR WISHES
Objectives for Nursing Students
• Become familiar with the advance care planning process
• Become familiar with the care options and services
available to seniors and where to access information
• Complete the Advance Care Planning Facilitator course
• Complete a presentation on advance care planning to a
group within our community
• Complete an ACP session with an individual and their
loved ones
©Gundersen Lutheran Medical Foundation
Advance Care Planning Facilitator
Course Objective
To provide the facilitator with the necessary
skills to assist an individual and their loved ones
through the advance care planning process,
which includes long term care needs and
healthcare decisions.
©Gundersen Lutheran Medical Foundation
Participants will be able to:
• Facilitate ACP for individuals and small groups
• Help complete written advance directives
• Make presentations to groups about ACP
©Gundersen Lutheran Medical Foundation
Group Exercise
1.) What does “quality of life” mean to you?
2.)What does “ heroics” mean to you?
Please take a few moments to answer these 2 questions
©Gundersen Lutheran Medical Foundation
©Gundersen Lutheran Medical Foundation
Session 1
From Advance Directives to
Advance Care Planning
• Gundersen Lutheran/ Respecting Choices
Advance Care Planning Model
• How do we get from Advance Directives to
Advance Care Planning?
©Gundersen Lutheran Medical Foundation
Respecting Choices®
An Advance Care
Planning
System That Works
Linking the Patient, Family, Provider
and Community
Linda Briggs, RN, MSN, MA
Assistant Director, Respecting Choices
& Ethics Consultant
©Gundersen Lutheran Medical Foundation
The Success in La Crosse
Suggests What is Possible
The team approach to ACP:
• Collaboration by major health organizations in
1991
• Components:
– Multiprofessional approach and training
– Multimodal community education
– Organization & community policies and
practices
Patients were routinely approached about and
assisted with ACP
©Gundersen Lutheran Medical Foundation
Gundersen Lutheran Respecting Choices
• After 2 years of full implementation the project had
significant impact on end-of-life planning and decision
making.
Of 540 adult deaths studied from April 1995- March
1996
-85% had written AD’s.
-96% had advance directives in their medical file.
-98% had evidence that wishes were followed as
death neared
Patients with AD:
- were more likely to be admitted to long term care
(65% vs.31%)& Hospice (29% vs. 11%)
-were less likely to die in the hospital
©Gundersen Lutheran Medical Foundation
How do we get from
Advance Directives to
Advance Care Planning?
• A cultural change will be required
• Organizational & community engagement
• Commitment to learning new skills and
practices
• Development of new standards of practice
©Gundersen Lutheran Medical Foundation
A statement from the Gundersen Lutheran
model (the developers of Respecting
Choices):
Gundersen Lutheran believes if incorporated as a routine
component of care with multiple professionals taking
responsibility for education and counseling, early in the course
of an illness (or ones life), advance care planning can truly become
a process and not an isolated event or signature on a document.
The challenge is to assist professionals ( and the people in our
community) in gaining the necessary knowledge and skills to
attain competency in advance care planning facilitation.
©Gundersen Lutheran Medical Foundation
Summary
• Sharing Your Wishes is an important initiative to increase public
awareness about the ACP process, increase communication
between elders and their loved ones & medical providers, and
to strengthen our system to ensure a persons’ health care
wishes are honored.
• ACP has proved to be successful in many other communities.
• To get from Advance Directives to Advance Care Planning
our community requires a cultural change with a commitment
to learn new skills and develop new practices.
©Gundersen Lutheran Medical Foundation
Session 2
Services and Care Options
for Seniors
in Genesee county
• Office for the Aging
• Care Options for Seniors
©Gundersen Lutheran Medical Foundation
Genesee County
Office for the Aging
Provides a variety of programs
and services to all county residents
who are 60 years of age and older
343-1611
Monday – Friday
8:30- 5 p.m.
©Gundersen Lutheran Medical Foundation
Genesee County Office for the Aging
Long Term Care Services
• Nutrition: Meals on
Wheels, Senior meal
programs, nutrition
counseling
• Medical Transportation
• Nursing Home
Counseling
• Home Care/ EISEP
©Gundersen Lutheran Medical Foundation
• Assistance with
applications for benefits
• Ombudsman program
• Assessments for seniors
with financial needs
Genesee County Office for the Aging
Information and referrals
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Housing for Seniors
Adult Day Care
Home Health Care
Respite
Nursing Homes
Personal Emergency
Response System
• Medical Services
©Gundersen Lutheran Medical Foundation
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Social Security Benefits
Weatherization referrals
Food stamps & Medicaid
Alzheimers services
Genesee County Office for the Aging
Information and Services
• Counseling
• Discount services
• Legal Services: POA,
Living Will, HCP,
Medicaid eligibility, Long
Term Care Insurance,
Financial Planning
• Volunteer PlacementRSVP
• Recreation programs and
activities
©Gundersen Lutheran Medical Foundation
• Caregiver Resource Center:
counseling and support
groups
• Community Education
• Newsletters
• Tax Preparation
• Notary services
• Photocopying
• Voter registration Site
CARE OPTIONS FOR SENIORS
IN
GENESEE COUNTY
www.co.genesee.ny.us
from the main menu select:
“Care Options for Seniors”
Your Link to Services in Genesee County
©Gundersen Lutheran Medical Foundation
Summary
• The Genesee county Office For the Aging has
many services and programs for adults 60 years
of age or older.
©Gundersen Lutheran Medical Foundation
Session 3
The Important Role of an
Advance Care Planning Facilitator
• ACP Facilitator definition
•ACP Facilitator qualifications
•ACP Facilitator roles and
responsibilities
©Gundersen Lutheran Medical Foundation
Advance Care Planning
Facilitator
A person who is able to guide others to understand
through the advance care planning process. This
includes reflecting on life values and goals,
examining support services, and understanding the
impact of future healthcare decisions.
©Gundersen Lutheran Medical Foundation
Facilitate
To Guide
To Help
To Assist
To Advance
©Gundersen Lutheran Medical Foundation
Advance Care Planning Facilitator
Qualifications
• Can come from any background or experience with a desire to
enhance the quality of life for seniors.
• Have good communication skills and the ability to be an active
listener.
• Be able to discuss sensitive issues.
• Have the ability to respect cultural, spiritual and personal
differences.
• Be able to remain non-judgmental, non-prying and to respect an
individuals choices.
• Maintain confidentiality
• Complete the Advance Care Planning facilitator training
program
©Gundersen Lutheran Medical Foundation
Advance Care Planning Facilitator
Role and responsibilities
• Be knowledgeable in the advance care planning process and
services available to seniors
• Initiate advance care planning discussions
• Provide education an the advance care planning process
• Facilitate discussions of advance care planning with seniors and
their loved ones.
• Assist seniors in the completion of advance directives
• Make referrals for other services when necessary
©Gundersen Lutheran Medical Foundation
Summary
• ACP facilitators must have good communication skills
and the abilities to discuss sensitive issues while
respecting cultural, spiritual & personal differences.
• ACP facilitators need to be knowledgeable in the ACP
process, services available to seniors, and have the
abilities to initiate and facilitate ACP with seniors
©Gundersen Lutheran Medical Foundation
You can make a difference
in the life of a
senior…
©Gundersen Lutheran Medical Foundation
by becoming a facilitator.
Session 4
Advance Care planning:
Understanding the concept
• How can we assist
people?
• Why is it necessary?
• What are the benefits?
For seniors
For loved ones
For medical providers
For the work place
©Gundersen Lutheran Medical Foundation
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Why is it avoided?
Why do we often fail?
When is it successful?
Local findings
Advance Care Planning
• A process of understanding, reflecting and
communicating preferences for future care, including care
options and health care decisions.
©Gundersen Lutheran Medical Foundation
Assisting with Advance Care Planning
• Encouraging people to review their wishes and expectations
with their loved ones, health care agent, physicians, lawyers
and spiritual advisors.
• Assisting people in completing the New York State Health
Care Proxy form, Living Will, DNR and Non-hospital DNR
forms.
• Instructing seniors to review and updating these forms
periodically and after life changing events.
• Emphasizing the importance of conducting ongoing
conversations about their wishes and expectations with their
loved ones, health care agent, physicians, lawyers and
©Gundersen Lutheran Medical Foundation
ADVANCE CARE
PLANNING
Why is it necessary?
Americans will live longer and healthier lives than
ever before. Life expectancy in one century has
gone from 47 to 75
©Gundersen Lutheran Medical Foundation
Advance care planning :Why is it necessary?
Most people will experience chronic illness or disability with
complex health issues in the last phase of their lives:
*8 out of 10 seniors 65 or older have at least 1
chronic condition
*5 out of 10 have at least 2 chronic conditions
*1 out of 2 people may require long term care
services
*1 out of 2 people may be unable to make decisions
for themselves during their dying process
©Gundersen Lutheran Medical Foundation
Advance care planning :Why is it necessary?
•Multiple changes and advancements in medical
technology, extending life.
•Health professionals typically treat when uncertain.
•Most of us will die under the care of health
professionals.
©Gundersen Lutheran Medical Foundation
Advance care planning: Why is it necessary?
•To ensure clinical care is consistent with the individuals
wishes.
•Multiple changes have occurred in the family structure.
•Loved ones have a significant chance of not knowing a
person’s views without discussion.
•To reduce an individuals concern regarding possible
burden placed on family and others.
©Gundersen Lutheran Medical Foundation
Advance Care Planning
why is it necessary?
• Currently under New York State law, no one,
not even a family member, has the legal right to
make health care decisions for a person if they
become incapacitated.
• Less than 25% of Americans have created some
form of plan outlining how they wish to be
treated in the last phase of their life.
©Gundersen Lutheran Medical Foundation
Why is it necessary?
How the Majority of
Americans Die
Over 75%
©Gundersen Lutheran Medical Foundation
How the Majority of
Americans Wish to Die
80%
Patricia Bomba, M.D. Vice President &
Medical Director, Geriatrics
Advance care planning affects many in our
community
2000 Census
County residents age sixty plus: 11,095
(18.5% of total pop, 3.2% increase from 1990)
People 85+ increased from 860 to 1,101
(28% increase)
By 2015:
People 85+ to increase to almost 1,400
NYS Office for Aging Project 2015
©Gundersen Lutheran Medical Foundation
The “Aging”
Today and Tomorrow
Source: Policy Committee – White House
Conference on Aging -- July 14, 2004
©Gundersen Lutheran Medical Foundation
Advance care planning
what are the benefits?
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©Gundersen Lutheran Medical Foundation
For the patient.
For the family/loved ones
For medical providers
For the work place
Advance Care Planning: Benefits
For the senior, frail elder.
• Maintain Control
• Achieve Peace of Mind
• Can make difficult
transitions easier
©Gundersen Lutheran Medical Foundation
• Assure wishes are
honored when they are
unable to communicate
them.
Advance Care Planning: Benefits
for family and loved ones
• Empowers and guides family/significant others in
making crucial health care decisions for a loved
one.
• Helps avoid family conflict over treatment options.
• Aids in coping with grief if they are clear that they
have followed the wishes of their loved one.
©Gundersen Lutheran Medical Foundation
Advance Care Planning: Benefits
for the medical providers
• Improves quality care by matching provided treatment
with an individuals preferences and decreasing
utilization of acute care services.
• Decreases unnecessary stress on staff.
• Reduces the possibility of litigation.
©Gundersen Lutheran Medical Foundation
Advance Care Planning: Benefits
for the medical providers
• Guides physicians in decision making.
• Reduces the amount of time in “crisis management”
for the final phase of life decisions.
• Reduces time spent in lengthy, repeated family care
conferences exploring whether to continue or forgo
medical treatment.
©Gundersen Lutheran Medical Foundation
Advance Care Planning: Benefits
for the work place
Reduce employee absenteeism
Nationally, 1 in 4 employees is involved with
caring for an older adult
©Gundersen Lutheran Medical Foundation
ACP: Why is it avoided ?
 Many have not considered the importance of ACP.
 Lack of information or unsure where to get information .
 It can be very personal and may elicit strong emotional reactions.
 It may be unclear how to start the conversation.
 It may raise issues that are difficult to resolve.
 Many believe it is for elders or the sick.
 May cause worry to loved ones.
©Gundersen Lutheran Medical Foundation
©Gundersen Lutheran Medical Foundation
Why is ACP sometimes avoided by
health care professionals?
 Lack of professional, training, skill and confidence.
 Believe they are adequately addressing ACP needs of their pt.
 Focused on completion of AD.
 Perceived lack of time .
 Lack of reimbursement.
 No developed system.
©Gundersen Lutheran Medical Foundation
Ways we often fail:
 People lack knowledge and understanding of services
available to them.
People’s values and preferences are not known.
Written plans do not reflect a persons preferences.
Written plans are often not available.
Written plans are not clear or are irrelevant.
©Gundersen Lutheran Medical Foundation
Advance Care Planning is successful when:
Future options are understood.
Options are considered based on the person’s values
and goals.
Choices are discussed with loved ones and medical
providers before a crisis.
A plan is formulated and supported by loved ones.
Health care documents are accessible.
©Gundersen Lutheran Medical Foundation
Local Findings
In Genesee County 4 community conversations with about 80
seniors were conducted in July/August 2005, the results:
KNOWLEDGE DEFICIT
• where to go for information about care
options and services available to seniors.
• terminology and definitions of advance
directives
• advance health care planning as a process
not a piece of paper
• proper completion of forms/documents
• need to update forms periodically
©Gundersen Lutheran Medical Foundation
Local Findings
LACK OF COMMUNICATION
• between family, loved ones, spiritual advisors and
person completing forms.
• between physicians and person completing forms
- 70% feel it would not be difficult to talk with their
physician about their wishes for end of life.
-80% had not talked with their physician about
end of life care.
©Gundersen Lutheran Medical Foundation
Local Findings
NEED TO EDUCATE ABOUT:
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Services available to seniors in Genesee county
Terms and definitions of advance directives
Advance care planning as a process
Proper completion of forms
Need to update forms
How to have conversations with families, loved
ones, spiritual advisors, physicians and medical
providers.
©Gundersen Lutheran Medical Foundation
Ways facilitators can improve the quality of life of people in our
community
• Encouraging ACP as an ongoing process not a one time event.
• Understanding the services and care options available for seniors in
Genesee County, referring individuals as appropriate.
• Assisting an individual to become more informed about their health &
wellness, their diagnosis & prognosis and the benefits & burdens of
treatments.
• Guiding an individual to explore, clarify and document their values,
beliefs, goals and wishes. Including appointing a Health Care Agent.
•
Informing seniors of the importance of taking control of their own.
lives.
©Gundersen Lutheran Medical Foundation
Summary
• ACP is an ongoing process that includes understanding,
reflecting, discussing and formulating a plan.
• ACP effects everyone in our community.
• ACP provides many benefits to the individual, their loved
ones, medical providers and spiritual leaders.
• ACP is successful when care options are understood &
considered based on a persons values and goals, a plan is
developed and supported by loved ones, and the healthcare
documents are accessible.
©Gundersen Lutheran Medical Foundation
Session 5
Advance Directives:
Understanding the language and tools
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Types of AD
Living Will
Power of Attorney
Health Care Agent
Health Care Proxy
Non-hospital Do Not Resuscitate
MOLST form
©Gundersen Lutheran Medical Foundation
An Advance Directive is...
a plan, indicating preferences for
future health care decisions if a
person becomes unable to speak for
themselves.
©Gundersen Lutheran Medical Foundation
Types of Advance Directives
I. Oral
II.Written
A. Formal (signed, dated, witnessed)
1. Meets statutory requirements
B. Informal
1. Physician’s note
2. Personal letter
©Gundersen Lutheran Medical Foundation
When can an AD be changed?
Advance Directives can be changed or
revoked at any time either in writing
or verbally. An Advance Directive
only takes effect when a person
becomes unable to make their own
decision due to illness or injury.
©Gundersen Lutheran Medical Foundation
Session 5
“Making Choices”
Video and discussion about the
importance of Advance Care Planning
©Gundersen Lutheran Medical Foundation
Session 6
An Overview of Law, Ethics & Medicine,
related to Advance Health Care Planning
• Right to Refuse Medical
Treatment
• Patient SelfDetermination Act
• Ethical basis for ACP
©Gundersen Lutheran Medical Foundation
• Life-Sustaining Treatments
*Benefits and Burdens of
Treatments
*CPR, including outcomes
*Nutritional Support
*Hydration
• Comfort Care
Right to refuse medical treatment
Competent adults have a right to refuse
medical/surgical treatment at any time.
This right continues even if the person is
incapable.
The most that a state can require is clear and
convincing evidence of an adult’s choices.
©Gundersen Lutheran Medical Foundation
Patient Self-Determination Act
A federal statute that requires health
organizations:
-To ask adults about advance directives at
admission.
-To provide written information about rights to
refuse treatment and to have an AD.
-To provide education to staff and community
about AD’s.
©Gundersen Lutheran Medical Foundation
Ethical Basis for ACP
Successful ACP promotes:
-Respect of patient’s values and wishes.
-Respect for right to self-determination.
©Gundersen Lutheran Medical Foundation
Decisions Should be Guided by:
-Determining the person’s goals…both medical
and non-medical.
-Considering the benefits and burdens for the
person of particular options or choices.
©Gundersen Lutheran Medical Foundation
Advance Health Care Planning:
creates an environment of shared
decision-making among individuals,
loved ones, and health professionals.
©Gundersen Lutheran Medical Foundation
Life-sustaining treatments:
Any treatment or intervention that is
used to sustain or prolong life.
©Gundersen Lutheran Medical Foundation
A treatment may be beneficial if it
is...
-Effective in prolonging life.
-Effective in restoring/maintaining function.
-Promotes goals/values of patient.
-Consistent with religious/cultural beliefs.
©Gundersen Lutheran Medical Foundation
A treatment may be considered
burdensome if ...
Results in more or intolerable pain.
Damages the body image or function.
Psychologically harmful.
Does not conform to their quality of life.
Cost is unacceptable.
©Gundersen Lutheran Medical Foundation
Choices about life-sustaining
treatments
When to start.
When to forgo (may choose limited time
trials of treatment).
How and when to maintain comfort.
©Gundersen Lutheran Medical Foundation
“Mixed Management”
Allows for choices to extend life as well
as choices that prepare for death and
provide comfort.
©Gundersen Lutheran Medical Foundation
Understanding the potential goals,
benefits/burdens, and outcomes for
life-sustaining treatments is
important.
CPR
Intubation /ventilation
Nutritional support
IV hydration
©Gundersen Lutheran Medical Foundation
What is Resuscitation?
Life-Sustaining Treatments
If your heart stops: Electrical shock to the heart and
injection of medications. If your breathing stops:
mechanical ventilation.
• Common Life-Sustaining Treatments
– CPR: Group of treatments used when
someone’s heart or breathing stops
– Mechanical Ventilation: Use of a machine
attached to a tube inserted through nose or
mouth that forces air into the lungs
– Artificial Hydration and Nutrition: Artificial
means of giving food or water
©Gundersen Lutheran Medical Foundation
CPR Outcomes
The success rate of CPR is often thought to be
much higher than it actually is.
Approximately 15% of hospitalized patients
survive and return to previous function.
Success rates in some populations are much
lower, e.g., in long term care, advanced cancer,
the success rate is < 2% .
©Gundersen Lutheran Medical Foundation
CPR Outcomes
• For those who do survive the CPR
attempt, complications include:
– Prolonged ICU stay on mechanical ventilation
– Decreased mental functioning
– Rib fractures
©Gundersen Lutheran Medical Foundation
Artificial Nutrition and Hydration
• When a person can no longer take food or fluid
by mouth, a feeding tube can sometimes be
used.
-Nasogastric tube
-Gastrostomy tube
• Or intravenously nutrition can be administered.
-Total Parenteral Nutrition
©Gundersen Lutheran Medical Foundation
Points about Nutritional Support
Nutrition delivered by tubes is a medical treatment
With a terminal illness, the body often can not
process food normally and forcing nutrition will
not prolong life.
 Naturally in the dying process there is decreased
appetite and thirst.
The word “starvation” is an emotionally charged
word that does not describe the cause of death.
©Gundersen Lutheran Medical Foundation
Comfort Care
• No aggressive or life prolonging treatments,
symptom control measures only.
• Providing optimal pain control and comfort
measures.
• Providing physical, emotional and spiritual support
to the terminally ill person and their family.
• Allowing natural death to occur.
Comfort Care does not mean “don’t treat” !
©Gundersen Lutheran Medical Foundation
Summary
• All Adults have a right to refuse treatments.
• Decisions for care options and treatments should be
guided by a person’s preferences and goals, while
considering the benefits and burdens of treatments.
• Life sustaining treatment is any treatment used to
prolong life.
• Decisions can be made about when to begin and
forgo treatment & when to provide comfort care.
©Gundersen Lutheran Medical Foundation
Session 7
Problem Solving Scenarios
Please break up into groups of 3
©Gundersen Lutheran Medical Foundation
Session 8
Advance Care Planning:
Facilitating the Process
• Basic skills at initiating ACP discussions
• Facilitation skills with different groups:
- the healthy adult
– the adult with incurable, progressive disease
– the adult expected to die within 12 months or
those in long term care
– the adult with new, serious conditions
©Gundersen Lutheran Medical Foundation
Basic Skills at Initiating ACP
• Affirm relationship;
support, time
• Introduce the concept
• Explain ACP
©Gundersen Lutheran Medical Foundation
• Explain ACP
• Assesses motivation,
knowledge, beliefs
• Encourage reflection
and discussion
Basic Skills at Initiating ACP
• Explore statements,
preferences
• Provide information,
worksheets
• Encourage loved ones
involvement
• Make referrals
• Assist in choosing an
appropriate agent
©Gundersen Lutheran Medical Foundation
• Develop a follow up
plan
Introduce the Concept
“I’d like to give you some information
that you can take with you to get
started thinking about the kinds of
choices you might want to make for
your future care.”
©Gundersen Lutheran Medical Foundation
Explain Advance
Care Planning
“This is called Advance Care Planning and it is
a good idea to take some time to understand
what’s involved, think about your choices, what
your goals and values are and then discuss
them with loved ones and others as needed. If
you have questions about your medical
condition, you can talk with your MD.”
©Gundersen Lutheran Medical Foundation
Encourage Reflection
and Discussion
“If you want to complete a document now, we
can have someone help you. However, we often
encourage people to take these materials
home, review them with loved ones and begin
to discuss the issues, choices and questions you
may have.”
©Gundersen Lutheran Medical Foundation
Develop a Follow-up Plan
“When you and your loved ones are ready to
learn more or complete a written plan,
please call me and we will schedule a time
that I can assist you in any way you need.”
©Gundersen Lutheran Medical Foundation
Skills to Engage people in
Advance Care Planning
Discussions
©Gundersen Lutheran Medical Foundation
Eliciting the person’s perspective
Take time to listen
Ask for person’s story about end-of-life care
Attempt to determine the person’s current health
status and their understanding of it.
Start with a focus on goals and what it might mean to
live well at this point or in future circumstances
©Gundersen Lutheran Medical Foundation
Before Developing a Plan, Address:
Expressed fears
Misunderstandings about basic facts or
processes
Gaps in knowledge
©Gundersen Lutheran Medical Foundation
Next, Explore and Clarify
•“What do you value most about your physical and
mental well being?”
•“What gives your life meaning and purpose?”
•“What are your religious or spiritual beliefs?”
• “What are your hopes and wishes for the final phase
of your life?”
•“Have you thought about living arrangements as you
age and become more frail?”
©Gundersen Lutheran Medical Foundation
• Common Misunderstood Expressions
 “No Heroics”
 “Don’t keep me alive if I am a vegetable.”
 “Don’t keep me alive on machines.”
 “If I am terminal, let me go.”
©Gundersen Lutheran Medical Foundation
Explain qualifications
for surrogate
 Willing and available.
 values and preferences.
• Understands what is important to you.
• Will talk about sensitive issues now.
• Will listen to your wishes.
• Can separate his/her feelings from yours.
• Willing to speak on your behalf.
• Would honor and act on your wishes.
• Able to handle challenges during difficult times.
©Gundersen Lutheran Medical Foundation
Facilitation Skills with Different Groups
of Adults
• Basic skills with all adults
• Adults with chronic, progressive disease
• Adults expected to die within 12 months or those in
long-term care
©Gundersen Lutheran Medical Foundation
What to discuss with all adults
“Are you familiar with the different long term
care services available to you?”
“Do you know where to go for information
about the services?”
©Gundersen Lutheran Medical Foundation
What to discuss with all adults
“Who would you want to make decisions if you
couldn’t?”
“What would be the goals of treatment if you
permanently lost the ability to know who you were,
who you were with, or where you were?”
“Do you have any religious, personal, or cultural views
that would affect treatment choices?”
©Gundersen Lutheran Medical Foundation
What to discuss with adults with a
chronic, progressive illness
The same issues as a healthy adult, plus…
Goals and benefits/burdens of initiating/forgoing
treatment most likely needed to attempt to sustain
life
Desires for comfort care for specific illness
©Gundersen Lutheran Medical Foundation
What to discuss with adults who may
die in the next 12 months
The same issues as a healthy adult as well as an adult
with a chronic, progressive illness, plus…
Review the person’s medical and non-medical goals.
Make decisions about CPR, hospitalization, nutritional
support, etc, if not already made.
Review options for comfort care and life closure.
©Gundersen Lutheran Medical Foundation
What to Discuss with all Adults:
Explore What is Most Important and How
They Want to Receive Care
• “What makes your day worthwhile?”
• “What experiences are most important for you to live well
• at this time and in the future of your life?”
• “How does your faith impact your health care decision
making?”
• “What gives you strength or sustains you in difficult times?”
©Gundersen Lutheran Medical Foundation
Explore What is Most Important and How
They Want to Receive Care
• “What fears or worries do you have about your illness or
medical care?”
• “Have the illnesses or deaths of loved ones influenced
your view of the medical system?”
• “What are your goals for care and where would you like to
receive care?”
• “Are there circumstances under which you would refuse
or discontinue treatment that might prolong your life?”
©Gundersen Lutheran Medical Foundation
Some Other Things to consider in
Pre-Planning:
• Completion of a Will: a legal document used to
divide assets and property after death.
• Organ donation.
• Burial arrangements.
©Gundersen Lutheran Medical Foundation
Summary
Skills at initiating ACP conversations must be
learned and incorporated as routine care.
Different facilitation skills are required for
different groups of adults.
Facilitation skills require practice and
experience to develop.
©Gundersen Lutheran Medical Foundation
Session 9
“Respecting
Choices: The
Facilitation Process with
a Healthy Adult”
video and discussion
©Gundersen Lutheran Medical Foundation
Session 10
Creating an Advance Directive
Communicating the Plan
©Gundersen Lutheran Medical Foundation
Basic Standards for Communication
Written plans are best.
Recommend the document that best meets
the needs of the individual.
Strive for clarity, accuracy, and completeness.
Encourage the agent and loved ones to be a
part of the conversations when ever possible.
©Gundersen Lutheran Medical Foundation
Living Wills are Limited
Only give instructions for a limited number
of circumstances
Often do not apply to needed decisions
No surrogate to make decisions
©Gundersen Lutheran Medical Foundation
Health Care Proxy’s
are typically best
A person can make decisions with MD in real
time.
May provide a wide range of instructions.
Applies to a wide range of health decisions.
©Gundersen Lutheran Medical Foundation
Statutory Requirements
Review Health Care Proxy form
Review Living Will form
©Gundersen Lutheran Medical Foundation
Summary
Assist individuals in selecting a communication plan
Understand/clarify terminology
Know statutory requirements
©Gundersen Lutheran Medical Foundation
Current Education of health care
professionals
Focused on completion of advance directives
No developed system to practice or work
No defined responsibilities or competencies
Inadequate or conflicting teaching resources
Little or no management or review of practice
Studies of professional’s knowledge of end-of-life issues reveal a lack
of awareness of ethical & legal rulings, but also continued
dissatisfaction and discomfort when placed in these situations
©Gundersen Lutheran Medical Foundation
The Role of the RN as an ACP Facilitator
• Assess the need for information
• Initiate conversation when cues arrive
• Provide accurate information on medical condition or
refer to MD
• Listen/Clarify
• Make appropriate referrals
• Provide emotional support
• Communicate choices
• Follow organizational policies
©Gundersen Lutheran Medical Foundation
Session 11
The Four Steps for Success
in
Advance Care Planning
©Gundersen Lutheran Medical Foundation
Before a crisis occurs or a treatment
option is considered take time to
explore your:
•
•
•
•
Health & wellness
Diagnosis & prognosis
Treatment benefits & burdens
Options & available services
©Gundersen Lutheran Medical Foundation
The Four steps for success in
Advance Care Planning
1.
REFLECT
Consider your personal values and
spiritual beliefs. Think about what is
important to you and how you want to
receive your care.
©Gundersen Lutheran Medical Foundation
The Four steps for success in
Advance Care Planning
2. CHOOSE
Select the best person to speak for you
if you become unable to speak for
yourself.
©Gundersen Lutheran Medical Foundation
The Four steps for success in
Advance Care Planning
3. TALK
Start the conversation…share your
wishes with your loved ones, health
care agent, medical professionals,
lawyers and spiritual advisors.
Continue the conversation throughout
your life.
©Gundersen Lutheran Medical Foundation
The Four steps for success in
Advance Care Planning
4. WRITE
Put your health care wishes in
writing and give a copy to your
loved ones, health care agent,
physicians, lawyers and spiritual
advisors. Keep copies on you at all
times.
Update the forms periodically.
©Gundersen Lutheran Medical Foundation
Imagine If….SYW Vision
• A majority of frail elders in Genesee County knew what
kind of last-phase-of-life care they wanted;
• Were able to talk about this with their family members and
medical providers and spiritual advisors;
• Had their wishes clearly expressed in a legal document;
• The document was accessible and used to direct and guide
their medical care and support services to improve their
quality of life during the last years of their life.
©Gundersen Lutheran Medical Foundation
Conclusion
Thank you for your participation!
•
•
•
•
Questions?
Comments?
Please complete a course evaluation
A certificate of completion for this course will
be mailed to you in the near future.
• Contact Cathie Plaisted at The Office for the
Aging 343-1611for any questions or for
literature and materials for your presentations.
©Gundersen Lutheran Medical Foundation