EEPPEECC

EEPPEECC

Advance CarePlanning

Advance CarePlanning

Module 1Module 1Module 1Module 1

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

Objectives . . .Objectives . . .

Define advance care planning, Define advance care planning, explain its importanceexplain its importance

Describe the steps of advance care Describe the steps of advance care planningplanning

Describe the role of patient, proxy, Describe the role of patient, proxy, physician, othersphysician, others

Define advance care planning, Define advance care planning, explain its importanceexplain its importance

Describe the steps of advance care Describe the steps of advance care planningplanning

Describe the role of patient, proxy, Describe the role of patient, proxy, physician, othersphysician, others

. . . Objectives. . . Objectives

Distinguish between statutory and Distinguish between statutory and advisory documentsadvisory documents

Identify pitfalls and limitations in Identify pitfalls and limitations in advance care planningadvance care planning

Utilize planning to help put affairs in Utilize planning to help put affairs in orderorder

Distinguish between statutory and Distinguish between statutory and advisory documentsadvisory documents

Identify pitfalls and limitations in Identify pitfalls and limitations in advance care planningadvance care planning

Utilize planning to help put affairs in Utilize planning to help put affairs in orderorder

What is advance care planning? . . .What is advance care planning? . . . Process of planning for future Process of planning for future

medical caremedical care

Values and goals are explored, Values and goals are explored, documenteddocumented

Determine proxy decision makerDetermine proxy decision maker

Professional, legal responsibilityProfessional, legal responsibility

Process of planning for future Process of planning for future medical caremedical care

Values and goals are explored, Values and goals are explored, documenteddocumented

Determine proxy decision makerDetermine proxy decision maker

Professional, legal responsibilityProfessional, legal responsibility

. . . What is advance care planning?. . . What is advance care planning? Trust buildingTrust building

Uncertainty reducedUncertainty reduced

Helps to avoid confusion and conflictHelps to avoid confusion and conflict

Permits peace of mindPermits peace of mind

Trust buildingTrust building

Uncertainty reducedUncertainty reduced

Helps to avoid confusion and conflictHelps to avoid confusion and conflict

Permits peace of mindPermits peace of mind

5 steps for successful advance care planning5 steps for successful advance care planning

1.1. Introduce the topic Introduce the topic

2.2. Engage in structured discussions Engage in structured discussions

3.3. Document patient preferences Document patient preferences

4.4. Review, update Review, update

5. 5. Apply directives when need arisesApply directives when need arises

1.1. Introduce the topic Introduce the topic

2.2. Engage in structured discussions Engage in structured discussions

3.3. Document patient preferences Document patient preferences

4.4. Review, update Review, update

5. 5. Apply directives when need arisesApply directives when need arises

Step 1: Introducethe topicStep 1: Introducethe topic Be straightforward and routineBe straightforward and routine

Determine patient familiarityDetermine patient familiarity

Explain the processExplain the process

Determine comfort levelDetermine comfort level

Determine proxyDetermine proxy

Be straightforward and routineBe straightforward and routine

Determine patient familiarityDetermine patient familiarity

Explain the processExplain the process

Determine comfort levelDetermine comfort level

Determine proxyDetermine proxy

Step 2: Engage is structured discussionsStep 2: Engage is structured discussions Proxy decision maker(s) presentProxy decision maker(s) present

Describe scenarios, options for careDescribe scenarios, options for care

Elicit patient’s values, goalsElicit patient’s values, goals

Use a worksheetUse a worksheet

Check for inconsistenciesCheck for inconsistencies

Proxy decision maker(s) presentProxy decision maker(s) present

Describe scenarios, options for careDescribe scenarios, options for care

Elicit patient’s values, goalsElicit patient’s values, goals

Use a worksheetUse a worksheet

Check for inconsistenciesCheck for inconsistencies

Role of the proxyRole of the proxy

Entrusted to speak for the patientEntrusted to speak for the patient

Involved in the discussionsInvolved in the discussions

Must be willing, able to take the Must be willing, able to take the proxy roleproxy role

Entrusted to speak for the patientEntrusted to speak for the patient

Involved in the discussionsInvolved in the discussions

Must be willing, able to take the Must be willing, able to take the proxy roleproxy role

Patient and proxy educationPatient and proxy education Define key medical termsDefine key medical terms

Explain benefits, burdens of Explain benefits, burdens of treatmentstreatments

Life support may only be short-termLife support may only be short-term

Any intervention can be refusedAny intervention can be refused

Recovery cannot always be predictedRecovery cannot always be predicted

Define key medical termsDefine key medical terms

Explain benefits, burdens of Explain benefits, burdens of treatmentstreatments

Life support may only be short-termLife support may only be short-term

Any intervention can be refusedAny intervention can be refused

Recovery cannot always be predictedRecovery cannot always be predicted

Elicit the patient’s values and goalsElicit the patient’s values and goals Ask about past experiencesAsk about past experiences

Describe possible situationsDescribe possible situations

Write a letterWrite a letter

Ask about past experiencesAsk about past experiences

Describe possible situationsDescribe possible situations

Write a letterWrite a letter

Use a validated advisory documentUse a validated advisory document A number are availableA number are available

Easy to useEasy to use

Reduces chance for omissionsReduces chance for omissions

Patients, proxy, family can take homePatients, proxy, family can take home

A number are availableA number are available

Easy to useEasy to use

Reduces chance for omissionsReduces chance for omissions

Patients, proxy, family can take homePatients, proxy, family can take home

Step 3: Document patient preferencesStep 3: Document patient preferences Review advance directiveReview advance directive

Sign the documentationSign the documentation

Enter into the medical recordEnter into the medical record

Recommend statutory documentsRecommend statutory documents

Ensure portabilityEnsure portability

Review advance directiveReview advance directive

Sign the documentationSign the documentation

Enter into the medical recordEnter into the medical record

Recommend statutory documentsRecommend statutory documents

Ensure portabilityEnsure portability

Step 4: Review, updateStep 4: Review, update

Follow up periodicallyFollow up periodically

Note major life eventsNote major life events

Discuss, document changesDiscuss, document changes

Follow up periodicallyFollow up periodically

Note major life eventsNote major life events

Discuss, document changesDiscuss, document changes

Step 5: Apply directivesStep 5: Apply directives

Determine applicabilityDetermine applicability

Read and interpret the advance Read and interpret the advance directivedirective

Consult with the proxyConsult with the proxy

Ethics committee for disagreementsEthics committee for disagreements

Carry out the treatment planCarry out the treatment plan

Determine applicabilityDetermine applicability

Read and interpret the advance Read and interpret the advance directivedirective

Consult with the proxyConsult with the proxy

Ethics committee for disagreementsEthics committee for disagreements

Carry out the treatment planCarry out the treatment plan

Common pitfallsCommon pitfalls

Failure to planFailure to plan

Proxy absent for discussionsProxy absent for discussions

Unclear patient preferencesUnclear patient preferences

Focus too narrowFocus too narrow

Communicative patients are ignoredCommunicative patients are ignored

Making assumptionsMaking assumptions

Failure to planFailure to plan

Proxy absent for discussionsProxy absent for discussions

Unclear patient preferencesUnclear patient preferences

Focus too narrowFocus too narrow

Communicative patients are ignoredCommunicative patients are ignored

Making assumptionsMaking assumptions

Preparation for the last hours of life . . . Preparation for the last hours of life . . . Advance planningAdvance planning

personal choicespersonal choices

caregiverscaregivers

settingsetting

Loss, grief, coping strategiesLoss, grief, coping strategies

Advance planningAdvance planning

personal choicespersonal choices

caregiverscaregivers

settingsetting

Loss, grief, coping strategiesLoss, grief, coping strategies

. . . Preparation for last hours of life. . . Preparation for last hours of life Educating / training patients, families Educating / training patients, families

and caregiversand caregivers

communicationcommunication

tasks of caringtasks of caring

what to expectwhat to expect

physiologic changes, eventsphysiologic changes, events

symptom managementsymptom management

Educating / training patients, families Educating / training patients, families and caregiversand caregivers

communicationcommunication

tasks of caringtasks of caring

what to expectwhat to expect

physiologic changes, eventsphysiologic changes, events

symptom managementsymptom management

Advance practical planning . . .Advance practical planning . . . Financial, legal affairsFinancial, legal affairs

Final giftsFinal gifts

bequestsbequests

organ donationorgan donation

AutopsyAutopsy

Financial, legal affairsFinancial, legal affairs

Final giftsFinal gifts

bequestsbequests

organ donationorgan donation

AutopsyAutopsy

. . . Advance practical planning. . . Advance practical planning Burial / cremationBurial / cremation

Funeral / memorial servicesFuneral / memorial services

GuardianshipGuardianship

Burial / cremationBurial / cremation

Funeral / memorial servicesFuneral / memorial services

GuardianshipGuardianship

Choice of caregiversChoice of caregivers

Be family first, caregivers only if Be family first, caregivers only if comfortablecomfortable

everyone comfortable in the roleeveryone comfortable in the role

seek permissionseek permission

change roles if stressedchange roles if stressed

Be family first, caregivers only if Be family first, caregivers only if comfortablecomfortable

everyone comfortable in the roleeveryone comfortable in the role

seek permissionseek permission

change roles if stressedchange roles if stressed

Choice of setting . . .Choice of setting . . .

Burdens, benefits weighedBurdens, benefits weighed

Permit family presencePermit family presence

privacyprivacy

intimacyintimacy

Burdens, benefits weighedBurdens, benefits weighed

Permit family presencePermit family presence

privacyprivacy

intimacyintimacy

. . .Choice of setting . . .Choice of setting

Minimize family burdenMinimize family burden

risk to career, personal economics, risk to career, personal economics, healthhealth

ghostsghosts

Alternate setting as backupAlternate setting as backup

Minimize family burdenMinimize family burden

risk to career, personal economics, risk to career, personal economics, healthhealth

ghostsghosts

Alternate setting as backupAlternate setting as backup

EEPPEECC

EEPPEECC Advance Care Advance Care

PlanningPlanning SummarySummary

Advance Care Advance Care PlanningPlanning SummarySummary