ADVANCE CARE PLANNING
CONVERSATIONS MATTER GOALS OF CARE DESIGNATIONS The Basics of Advance Care Planning & Goals of Care: What You Need to Know 1
Today’s Objectives • Advance Care Planning overview • Goals of Care overview • Green Sleeve overview • Resources
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• • Alberta Health
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Services
www.albertahealthservices. ca
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What Is Advance Care Planning? Advance Care Planning is a process whereby a capable adult: • Thinks about and communicates values and wishes for medical care • Appoints someone to make healthcare decisions on their behalf • Documents their plan 4
Where we used to be: • Full functioning until sudden death – no ongoing decline. • Medicine could do very little in terms of curing illness • This was the normal trajectory of aging/death!
(Gawande, 2014; Geri-EM, 2016)
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Where we are now:
• Aging/death characterized by long period of decline of function before death. • Today, these 3 trajectories account for 85% of all deaths. (Geri-Em, 2016 ; Lunney, Lynn ,& Hogan, 2002)
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What we already know: • Drastic age distribution changes globally • We can expect to be in a state of “vulnerable frailty” for several years before death. • At time of death: – 42.5% require decision-making – 70.3% lack capacity
(Gawande, 2014; Silveira et al., 2010) 77
5 Steps to Advance Care Planning 1. Think about your wishes and values 2. Learn about your own health 3. Choose someone to make decisions and speak on your behalf 4. Communicate your wishes and values about health care 5. Document in a Personal Directive
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Personal Directive Very different from a Will or an Enduring Power of Attorney Personal Directive: • Legal form to appoint agent • Document healthcare wishes/instructions
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Personal Directive • No standard format for Personal Directives in Alberta. – Signed, Dated, Witnessed = legal. The personal directive only comes into effect if someone becomes incapable of making health/personal decisions. Formal process involved.
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Enacting a Personal Directive
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Personal Directive • • • •
Needs to be completed by competent adult If no personal directive Options: Guardianship court process Form 6 completed by physician for medical decisions only
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Care Consistent with Patient Values & Goals
ACP Conversations Values Wishes Fears Illness expectations
Goals of Care Conversations Previous discussions, values, preferences Understand illness Prognosis Anticipated outcomes Appropriate treatment options
Documentation
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Goals of Care
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Goals of Care Video
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Goals of Care Designations (GCD’s) • GCD’s provide more specific direction regarding: specific health interventions transfer decisions locations of care • R1, R2, R3, M1, M2, C1, C2 • Medical Order – written by ‘Most Responsible Health Practitioner”
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Advance Care Planning & Goals of Care Designation Policy Level 1 Policy/Procedure Outlines responsibilities regarding: • Advance Care Planning and Goals of Care conversations (1.1) • Obtaining and understanding Personal Directives (1.1) • Documentation - where you document matters! (3.2) Applies to all members of a patient/client’s healthcare team regardless of discipline. 18
Everyone’s Role: Documentation Tracking Record for ACP/GCD Discussions
Goals of Care Designation (GCD) Order Form
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Patient has personal 2014-02-27 directive in green sleeve, to discuss Goals of Care with Dr. at next visit
A Shirley HCA
2014/7/7
Patient, Barb (mother), Pat- HCA at group home
A Shirley HCA
Discussed effective treatment options, patient agreed that C1 Goals of Care is appropriate and in line with his wishes. This is appropriate given underlying condition.
Patient, Mother, Dr Myles (PCN MD)
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Jeremy Myles, Family Medicine Physician
JMyles Bowmont
PCN
The Green Sleeve – “Health Passport” Personal Directive (copy)
Green Sleeve
Tracking Record for ACP Discussions
Goals of Care Designation Order Form
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Green Sleeve Video
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Role of your staff • Know the Goals of care of your clients • Know the role of the Green Sleeve • Act according to the medical order • Know who the decision maker is • Chart any relevant information to the clients goals of care 25
What can we offer? • Consultation/Collaboration regarding process and procedure • Education for staff and clients • Education materials
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Resources • AHS “Conversations Matter” website: www.conversationsmatter.ca • Office of the Public Guardian: www.humanservices.alberta.ca/guardia nship- trusteeship/office-publicguardian.html
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Thank You! AHS Advance Care Planning educators (Calgary zone): Suzanne Tinning RN,MN,CHPCN(C) Suzanne.tinning@ahs.ca 403-955-8013 Alexandra Kushliak, BA,BSW,RSW Alexandra.Kushliak@ahs.ca 587-581-6448 28
Questions?
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