Advance Care Planning Collaboration 101

Transcription

1 Advance Care Planning Cllabratin 101 Stephanie VanSlyke, RN ACP Facilitatr Ethics Cnsultant Michigan Hme Care & Hspice Assciatin

2 Overview Defining the prcess f Advance Care Planning (ACP) Why is ACP imprtant? Hw WE fail ur patients Fstering Change Cllabratin

3 Definitin: Advance Care Planning A prcess f reflectin, gal setting, and determinatin f desired future medical decisins.

4 Why is advance care planning imprtant? One in fur f us, in this rm, will need smene t make end-f-life decisins abut ur medical care. Medicare spent $50 millin dllars n the last 6 mnths f life Patients w/ end-f-life discussins preferred medical treatment fcused n relieving pain & discmfrt ver life-extending therapies. NEJM, April 1, 2010 Thse with advance directives ften receive less aggressive treatment when death is near. JAMA, Aug. 2008, Vl. 300, Patients with advance directives are much less likely t die in the hspital. JAMA, Nv 9, 2011.

5 MI End f Life Data: Medicare Beneficiaries 2011 During the last 6 mnths f life 71% f the patients had at least ne ED visit 65% f patients admitted t an inpatient stay at least nce 34% f patient were readmitted within 30-days f discharge 47% f terminal hspitalizatins included an ICU admissin $17,285 is the average inpatient spending per patient $26,541 is the average spending amng thse that had an inpatient admissin $19,414 inpatient average spending n terminal hspitalizatins Kaiser Family Fundatin: January 14, 2015

6 Hw WE fail ur patients WE make decisins that are nly disease centered; thus, we lse fcus f the individual WE fail t cmmunicate frm ne care setting t anther WE dn t have n-ging cnversatins WE dn t fster updating plans ver time WE frce decisins int bxes by cnstruing chices as either treating the disease r fcusing n cmfrt

7 WE can fster change WE can encurage advance care planning sner WE can share cmmunicate frm ne care setting t anther WE can add advance care planning t rutine physicals WE can cllabrate t create a prductive prcess, reduce repetitin, and fster culture change

8 Shcking Statics? Statics indicate: 100% - We are all ging t die. Statics indicate: 100% - We will all face death f a lved ne at sme pint during ur lifetime. We spend a lt f time and effrt n treatments with much lwer statics.

9 Missed pprtunities Studies reveal the impact f life limiting illnesses and ptentially avidable hspitalizatins Life Limiting illnesses CHF estimated ver 1 millin hspitalizatins each year CHF ften causes ther c-mrbidities (HTN, DM, CAD) Cancer COPD Diabetes Alchl/Drug Addictin Natinal Center fr Health Statistics:

10 WE can fster change WE can encurage earlier cnversatins Nt just at end f life Nt nly when there is a significant diagnsis Nt nly fr the elderly Shuld start talking abut death at a yung age Lss f a pet Stmping a bug Grandma/grandpa dies

11 WE can fster change WE can add advance care planning t rutine physicals Prvide training n hw t incrprate ACP int primary care Making this a standard fr annual visits WE need t be hnest with ur patients Planning fr a gd death requires knwing that ne is dying. Perceptins vary significantly (see next slide)

12 Lved Ones Expectatins vrs. Physician Expectatins Physician 93% *1 yr estimatin after trach placement Lved Ones 71% 83% 43% Be Alive 6% Live Independently 4% Have Gd Quality f Life Cx, C. E., Martinu, T., Sathy, S. J., Clay, A. S., Chia, J., Gray, A. L.,... Tulsky, J. A. (2009). Expectatins and utcmes f prlnged mechanical ventilatin. Critical Care Medicine, 37(11), DOI: /CCM.0b013e3181ab86ed

13 WE can fster change WE can share cmmunicate frm ne care setting t anther Set up systems fr sharing healthcare decisin making dcuments Create standardized language

14 WE can fster change WE can cllabrate t create a mre prductive prcess Knw yur rle in this prcess Identify ways t reduce repetitive wrk

15 Cllabratin!!! Primary Care, Hme Care, Hspice, Palliative Care, Acute Care, ECF, SNF, AFC.etc

16 Enhancing ACP Training ACP facilitatrs in primary care settings Create grup settings/wrkshps Create referral prcess with lcal agencies r yur lcal hspitals advance care planning department. Encurage ACP at discharge frm hspitalizatin

17 ACP gals Nrmalize ACP We d this w/ all ur patients at intake because we knw that we can t hnr yur wishes if we dn t knw what they are. This is part f a new initiative t make sure we keep yu and yur wishes at the center f the care we deliver t yu ACP, by definitin, must be patient centric, nt clinician driven. Requires Understanding Reflectin Discussin Encuragement thrugh multiple cnversatins

18 Lets Review The prcess f Advance Care Planning (ACP) Why is ACP imprtant? Fstering Change Cllabratin What s next? The secnd cnversatin.

19 Step by Step prcess fr ACP in primary care

20 Initial Meeting: 1. Assess mtivatin, knwledge and beliefs related t ACP 2. Identify understanding f ACP and AMD s. 3. Explre understanding f chrnic illness 4. Explre past experiences 5. Explre what living well means 6. Explre cultural, religius, spiritual, r persnal beliefs 7. Explre ptential healthcare agent(s) 8. Prvide a summary and fllw-up

21 Step 1: Assessing Mtivatin, Knwledge, & Beliefs Can yu tell me what yu understanding abut advance care planning? Defining: ACP: This is planning fr all adults. It is thinking abut future healthcare decisin if yu had a sudden event, like a car accident r illness, and culd nt make yur wn decisins. This planning will help yu and the persn yu chse understand yur gals and values fr living well. AMD: it s imprtant t write dwn yur gals, values, and preferences. This is called an advance directive, and it allws yu t chse a persn wh can make healthcare decisins fr yu. This persn ONLY makes decisins if yu cannt make them fr yurself.

22 Step 2: Identify understanding f ACP & AMDs What cnversatins have yu had abut pssible medical treatments with yur family r lved nes? What fears r cncerns d yu have abut planning? What d yu hpe an AMD will d fr yu in the future?

23 Step 3: Explre understanding f illness Tell me what yu understand abut yur illness. Have there been any changes with yur illness in the past few mnths? What prblems d yu think yu may have in the future frm yur illness?

24 Step 4: Explre past experiences Tell me briefly abut any experiences yu have had with family r friends wh became seriusly ill r injured (like a car accident r grandparents). What did yu learn frm that experience? Have yu been in the hspital recently because f yur illness? What did yu learn frm that experience? Are there any ther experiences yu ve had related t medical care?

25 Step 5: Explre what living well means What des living well mean t yu? If yu were having a gd day, what wuld be happening n that day? What are sme things yu really enjy ding? What wrries yu mst abut yur illness? What fears d yu have abut yur illness? Wh r what helps yu when yu face serius challenges in life?

26 Step 6: Explre unique cultural, religius, spiritual, r persnal beliefs What cultural, religius, spiritual, r persnal beliefs d yu have that might help yu chse the care yu wuld want, r wuld nt want? Are there cultural, religius, r spiritual practices that are imprtant t yu r give yu cmfrt, such as praying, singing, r eating certain fds? Wuld yu like t talk t smene abut these beliefs r cncerns?

27 Step 7: Explre ptential healthcare agent One f the mst imprtant decisin we encurage peple t make is chsing smene yu trust t make healthcare decisins fr yu. This persn wuld nly make decisin if yu had a sudden event and culd nt make yu wn decisins. I d like yu t imagine a scenari: a sudden event like a car accident r an illness that left yu unable t cmmunicate. Wh wuld yu chse t be yur healthcare decisin maker?

28 Step 7 (cnt): Explre ptential healthcare agent It is imprtant t think carefully abut his decisin. There are fur qualities yu shuld lk fr. A healthcare agent shuld be willing t: Accepts the respnsibility this rle entails, Talk abut yur gals, values, and preferences, Fllw yur decisin (even if he r she des nt agree with them), and Make decisins in difficult mments that reflect yur wishes Hw will yu explain the rle f healthcare agent when yu talk t yur chsen persn?

29 Step 7: Explre healthy adult decisin What wuld yu tell yur healthcare agent t d n yur behalf if yu suddenly, as a result f an unexpected accident, fund yurself permanently unable t knw wh yu are, where yu are r wh is cming t visit yu?

30 Step 8: Prvide a summary t the patient T prepare the patient t g hme w/ a blank r partially cmpleted AMD, cmplete a summary sheet that reminds them f the significant grund cvered in cnversatin. (see handut) Schedule a fllw up meeting t include their healthcare agent and their draft dcument. Next ACP sessin tpics: Patients understanding f current health status & their chrnic illness Intrduce infrmed decisin making abut CPR status

31 What s next Keep the cnversatin ging Next ACP sessin tpics: Assess patients n ging understanding f current health status & their chrnic illness Make recmmendatins fr future care based n patient gals Start with gals, NOT interventins. Intrduce infrmed decisin making abut CPR status