Anna Rahman, PhD, MSW ADVANCE CARE PLANNING Part 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

 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 Curriculum Session 8

Teleconference Instructions 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 If the leader is not on the call when you call in, please wait 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 PLANNING Part 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 PLANNING Part I: The Institutional Perspective Insert picture

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

 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 PLANNING Part 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 PLANNING Part 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 PLANNING Part 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 PLANNING Part 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 PLANNING Part 2: The Individual Perspective

Advance Care Planning The 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 PLANNING Part 2: The Individual Perspective

Advance Care Planning The 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 PLANNING Part 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 PLANNING Part 2: The Individual Perspective

ADVANCE CARE PLANNING Part 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 PLANNING Part 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 PLANNING Part 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 PLANNING Part 2: The Individual Perspective Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:

ADVANCE CARE PLANNING Part 2: The Individual Perspective Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:

ADVANCE CARE PLANNING Part 2: The Individual Perspective Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:

ADVANCE CARE PLANNING Part 2: The Individual Perspective Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:

ADVANCE CARE PLANNING Part 2: The Individual Perspective Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:

ADVANCE CARE PLANNING Part 2: The Individual Perspective Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:

ADVANCE CARE PLANNING Part 2: The Individual Perspective Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294: 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 PLANNING Part 2: The Individual Perspective Please wait while the video is showing

ADVANCE CARE PLANNING Part 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 PLANNING Part 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 PLANNING Part 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.  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 ( Resources for ACP and End-of-Life Care ADVANCE CARE PLANNING Part 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-w ide. Implementation Activities Before the Next Session: ADVANCE CARE PLANNING Part 2: The Individual Perspective

 Un-mute the line:Press # 6 Please re-mute your line after talking: Press * 6  Questions and suggestions on Session 8 can also be directed to Dr. Rahman by at: Please insert in the Subject Line: “Question about the INTERACT Curriculum” For teleconference participants: Questions, Suggestions, Comments? ADVANCE CARE PLANNING Part 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 below  For teleconference participants, check the date and time for the next session ADVANCE CARE PLANNING Part 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 PLANNING Part 2: The Individual Perspective