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

 If you are participating in a teleconference proceed to the next slide for instructions  If you are reviewing this session as a self- learning activity:  Proceed to slide # 4  Click the speaker at the bottom of each slide to listen to the audio  If you do not have audio, click on “View” on the toolbar, and select “Normal” to view the text below each slide – if necessary select “Zoom” to make all of the slide and text visible. INTERACT II Curriculum Session 7

Teleconference Instructions If the leader is not on the call when you call in, please wait INTERACT II Curriculum Session 7 Call in Number Conference Code # To un-mute your line to ask questions: Press # 6 After asking your question (s) re-mute your line: Press * 6

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 ADVANCE CARE PLANNING Part I: The Institutional Perspective

 Ruth Tappen, EdD, RN, FAAN is an Eminent Scholar and Professor at the Christine E. Lynn College of Nursing Florida Atlantic University ADVANCE CARE PLANNING Part I: The Institutional Perspective

The INTERACT Interdisciplinary Team Laurie Herndon, GNP Mass Senior Care Foundation Gerri Lamb, PhD, RN, FAAN Arizona State University Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Sanya Diaz, MD Florida Atlantic University John Schnelle, PhD Vanderbilt University Sandra Simmons, PhD Vanderbilt University Annie Rahman, MSW Miami University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence Alice Bonner, PhD, GNP Center for Medicare and Medicaid Services In collaboration with participating nursing homes ADVANCE CARE PLANNING Part I: The Institutional Perspective

 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 Part I: The Institutional Perspective

ADVANCE CARE PLANNING Part I: The Institutional 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  Document these discussions and their results

ADVANCE CARE PLANNING Part I: The Institutional 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 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 CARE PLANNING Part I: The Institutional Perspective 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 ADVANCE CARE PLANNING Part I: The Institutional Perspective 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 ADVANCE CARE PLANNING Part I: The Institutional Perspective Categories of Orders on the Form

ADVANCE CARE PLANNING Part I: The Institutional Perspective There is now a national effort to implement POLST/MOLST

 Each state regulates the use of advance directives differently ADVANCE CARE PLANNING Part I: The Institutional Perspective Advance Directives National Use of POLST

ADVANCE CARE PLANNING Part I: The Institutional Perspective 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

ADVANCE CARE PLANNING Part I: The Institutional Perspective Advance Care Planning (ACP) 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 4 th 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 4 th hospital admission Sam - a 101 year old long-stay resident ADVANCE CARE PLANNING Part I: The Institutional Perspective Advance Care Planning (ACP) Could some of these hospitalizations, intensive care, and PEG tube been avoided by better ACP?

ADVANCE CARE PLANNING Part I: The Institutional Perspective Advance Care Planning 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

ADVANCE CARE PLANNING Part I: The Institutional Perspective Advance Care Planning 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

ADVANCE CARE PLANNING Part I: The Institutional Perspective Please wait while the video is showing

ADVANCE CARE PLANNING Part I: The Institutional Perspective Advance Care Planning How?  The next INTERACT II Curriculum session will discuss the use of INTERACT II ACP tools and other resources

Goal 6Goal 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. ADVANCE CARE PLANNING Part I: The Institutional Perspective

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 ADVANCE CARE PLANNING Part I: The Institutional Perspective Adapted from:

ADVANCE CARE PLANNING Part I: The Institutional Perspective 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) Seven Steps to Improve ACP in Your Facility

ADVANCE CARE PLANNING Part I: The Institutional Perspective 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 Seven Steps to Improve ACP in Your Facility

ADVANCE CARE PLANNING Part I: The Institutional Perspective 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 Seven Steps to Improve ACP in Your Facility

Documenting ACP in Your Facility ADVANCE CARE PLANNING Part I: The Institutional Perspective AdvanceCarePlanning_TAW_Guide.pdf Adapted from:

Documenting ACP in Your Facility ADVANCE CARE PLANNING Part I: The Institutional Perspective AdvanceCarePlanning_TAW_Guide.pdf 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.  Alzheimer’s Association - Comprehensive recommendations aimed at improving communication and care at end of life.  Caring Connections – downloadable educational information and forms ( - 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 ( ADVANCE CARE PLANNING Part I: The Institutional Perspective 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: ADVANCE CARE PLANNING Part I: The Institutional Perspective

 Un-mute the line:Press # 6 Please re-mute your line after talking: Press * 6  Questions and suggestions on Session 7 can be sent to me at or also be directed to Dr. Ouslander by at: Please insert in the Subject Line: “Question about the INTERACT II Curriculum” For teleconference participants: Questions, Suggestions, Comments? ADVANCE CARE PLANNING Part I: The Institutional Perspective

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 below  For teleconference participants, check the date and time for the next session ADVANCE CARE PLANNING Part I: The Institutional 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 #7 Quiz and Evaluation ADVANCE CARE PLANNING Part I: The Institutional Perspective