Helping your patients Have a say in their health care

Objectives

• The who, what, where, when and how of ACP

• ACP resources &WRHA ACP policy

• ACP definitions

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•the overall process of dialogue, knowledge sharing, and informed decision-making that needs to occur at any time when future or potential life threatening illness treatment options and goals of care are being considered or revisited.

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Advance Care Planning (ACP)

• ACP is process of communication between the patient/substitute decision maker and the health care team.

• ACP goals of care discussions should take place in advance of anticipated deterioration or acute illness including surgery.

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What is Advance Care Planning (ACP)?

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• Is a Manitoba document that originates from the Health Care Directives Act.

• A legal document (sometimes referred to as a “living will”) used to capture an individuals wishes for medical care and treatments

• Recognizes mentally capable individuals have the right to consent or refuse to consent to health care treatment

Health Care Directive

• Indicates that these wishes should be respected even after the individual is no longer able to participate in decisions regarding their health care treatment

• Individual writes their instructions about the treatment they would accept or refuse

• Names a proxy to speak for the individual if they are unable to speak for themselves

Health Care Directive

• Is someone you choose and name in your directive to act for you in the event you are not able to make such judgments and speak on your own behalf.

• It is not possible to anticipate every set of circumstances, your proxy has the power to make health care decisions for you based on what you have told your proxy about your wishes and the information in your directive.

What is a Proxy?

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Proxy/Substitute Decision Maker

•refers to a third party identified to participate in decision making on behalf of an individual who lacks capacity.

•the task of the substitute decision maker is to faithfully represent the known preferences, or if the preferences are not known, the interest of the individual lacking capacity.

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Capacity

•An individual has capacity to make health care decisions if s/he is able to understand the information that is relevant to making a decision & able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.

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• Compassionate end of life care and the opportunity for organ donation is the right of every Manitoban, and the responsibility of all members of the donation and healthcare team.

• Individuals should consider if organ and tissue donation is important to them, talk with their families about their decisions and register their intent to be a donor at www.signupforlife.ca.

• Registration takes two minutes and requires three pieces of information – name, birthdate and nine-digit number on your Manitoba Health card.

Becoming an organ & tissue donor

• Nearly everyone has the potential to be an organ and tissue donor. The health of the donor, not the age, is the most important consideration.

• Organ donation occurs after brain death. Everyone is encouraged to discuss their final wishes with their families in a calm setting, not during a crisis. Families are required to provide consent on behalf of the patient, so it is important for families to know how to honour donation decisions.

• For more information, visit www.transplantmanitoba.ca or contact the program at 204-787-1897.

Becoming an organ & tissue donor

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WRHA Advance Care Planning Goals of Care

• An inpatient form used to recorded agreed upon goals of care reached through full & completed ACP discussion with Patient and /or Substitute Decision Maker/Proxy

Understanding the Differences

Health Care Directive

WRHA Advance Care Plan Goals of Care Form

Protected by legislation

Policy driven

Initiated by the person

Initiated by the health care team

Completed only if person is competent

Enables discussion with family where person is no longer competent

Legally binding document

Consensus based document

Goals of Care •the intended purposes of health care interventions and support as recognized by both a patient or substitute decision maker and the health care team

•on the goals of care form, three options exist: = Comfort care excluding attempted resuscitation = Medical care excluding attempted resuscitation = Medical care including attempted resuscitation

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Goals of Care •Comfort Care (C) –interventions are directed at maximal comfort, symptom control, and maintenance of quality of life. Attempted Cardiopulmonary Resuscitation [CPR] (trying to restart with heart after it has stopped beating) will not be tried.

•Medical Care (M)- interventions are for the usual medical care that is appropriate to treat and control the patient’s condition. The consensus is that the patient my benefit from, and are accepting of, any appropriate investigations / interventions that can be offered. Attempted CPR will not be offered.

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Goals of Care •Resuscitation (R) –interventions are for the usual medical care that is appropriate to treat and control the patient’s condition. The consensus is that the patient my benefit from, and are accepting of, any appropriate investigations / interventions that can be offered, including attempted CPR.

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Key Questions And Resources

Who can initiate an ACP discussion?

• All members of the health care team can initiate the discussion

• Key members of the health care team that often have these discussions include social workers, case coordinators, physicians, nurses, etc.

• Patients & their family can also initiate the discussion

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Who needs to be involved in an ACP

conversation?

•

The patient, or substitute decision maker The patient may also choose others to participate Member or members of the health care team The Health Care Team may involve others as appropriate

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When would I initiate a conversation?

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ACP discussions will be initiated whenever future treatment options or goals of care need to be considered or revised, regardless of facility, site or community location.

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When & where would I initiate a conversation?

• It may be appropriate to have these conversations routinely on admission (e.g. PCH) or even prior to admission (e.g. in pre-operative assessment clinic).

• Patients who have an existing ACP will have their old forms converted to the new advance care planning goals of care format with their next care plan review.

• Review or complete form before Home Care or Palliative Care client is being transferred to hospital.

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What if a patient requests to

review their Goals of Care?

• The health care team will respond within 72 hours or sooner if the patient’s clinical situation warrants more immediate attention as per policy 110.000.200

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Things to consider when starting an ACP

conversation

•

•

•

The health care team shall ensure that the patient / substitute

decision maker receives full and complete information about:

the nature of the individual’s current condition

prognosis

treatment options including benefits / burdens resources for patients: ACP patient Workbook, discussion with members of the health care team and online

What techniques would I use to participate in these

conversations?

• Therapeutic communication techniques are essential in ACP conversations.

• Helpful tips, suggestions and other ACP

communication resources are available online.

English is not my patient’s first

language. What Can I Do?

The health care team must request the services of a trained health interpreter when patients have limited English proficiency (call 788-8585)

What additional resources are

available?

• Regional ethics • Social Work • Indigenous Health • Spiritual care • Patient representatives • Clinical experts • ACP patient workbook

Health care team needs to make certain the patient is aware of these resources

What happens if consensus cannot be reached?

• all available resources should be used in attempts to reach consensus

• if consensus cannot be reached, the “advance care planning - goals of care” form will not be completed

• in such situations, health care professionals will continue to be guided by the standards of practice of their respective regulatory bodies

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• WRHA advance care planning goals of care form Policy:110.000.200

Supporting Documents

• ACP patient workbook

Supporting Documents

How to complete an ACP Goals of Care Form

• First, the health care team shall ensure ACP goals of care discussions occur prior to the completion or revision of the “ACP - Goals of Care” form.

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What if a Health Care Directive already exists?

A valid Health Care Directive that is completed by a patient will be respected unless requests made within the Health Care Directive are not consistent with accepted health care practices.

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Procedure if a Health Care Directive already exists

• check the chart or ask the patient for an existing health care directive

• ensure a copy is placed in the chart or scanned into the epr under the contacts / directives section

• a Health Care Directive will help to guide further discussions of the patient’s wishes in completing the new form

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What happens when an ACP is reviewed?

• if the ACP has not changed, it will be noted on the ACP form that a review has taken place

• if the ACP changes, the current ACP goals of care form shall be voided by writing “no longer in effect” diagonally across the form along with the date and signature of the health care team member

• if created, the new ACP goals of care form will precede the old form in the chart

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ADVANCE CARE PLANNING GOALS OF CARE

Refer to WRHA Advance Care Planning Policy # 110.000.200 prior to completing this form

Is there an existing Health Care Directive? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No

Yes

(If yes, it shall guide further discussions as an indication of the Patient/Client/Resident’s wishes at the time of writing)

Advance Care Planning (ACP) is the overall process of dialogue, knowledge sharing and informed decision making that needs to occur at any time when

future or potential life threatening illness treatment options and Goals of Care are being considered or revisited. This form is used to record agreed upon

Goals of Care reached through full and complete ACP discussions with the Patient/Resident/Client and/or Substitute Decision Maker about the nature of

the individual’s current condition, prognosis, treatment/procedural/investigation options, and expected benefits or burdens of those options.

GOALS OF CARE (Check the box that best describes the Patient/Resident/Client Goals of Care)

C = Comfort Care - Goals of Care and interventions are directed at maximal comfort, symptom control and maintenance of quality of life excluding

attempted resuscitation.

M = Medical Care - Goals of Care and interventions are for care and control of the Patient/Resident/Client condition. The Consensus is that the

Patient/Resident/Client may benefit from, and is accepting of, any appropriate investigations/ interventions that can be offered excluding attempted

resuscitation.

R = Resuscitation – Goals of Care and interventions are for care and control of the Patient/Resident/Client condition. The Consensus is that the

Patient/Resident/Client may benefit from, and is accepting of, any appropriate investigations/ interventions that can be offered including attempted

resuscitation.

No Yes

If the required care is not available in current location or setting, does the Patient/Resident/Client want to be transferred to alternate

facility? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Indicate all individuals who participated in Goals of Care discussion(s) by checking appropriate box(es).

Patient/Resident/Client

Family Member(s) Substitute

Decision Maker Health Care

Provider(s)

Print Name: �������������������������������������������������������������������������������������

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������������ Print Name(s): �������������������������������������������������������������������������������������

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Document details of the Patient/Resident/Client specific instructions or wishes and/or details of discussion with the individuals indicated above. (Refer to date/time of Progress Note entry if more space is required):

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Name & Designation of Health Care Provider Signature of Health Care Provider D D M M M Y Y Y YA

(Physician’s signature is required when patient is a client of the Public Trustee)

The Goals of Care were reviewed with the Patient/Resident/Client and/or Substitute Decision Maker and no change to the form is required.

Name & Designation of Health Care Provider Signature of Health Care Provider D D M M M Y Y Y Y

(Physician’s signature is required when patient is a client of the Public Trustee)

Name & Designation of Health Care Provider Signature of Health Care Provider D D M M M Y Y Y Y

(Physician’s signature is required when patient is a client of the Public Trustee)

Name & Designation of Health Care Provider Signature of Health Care Provider D D M M M Y Y Y Y

(Physician’s signature is required when patient is a client of the Public Trustee)

If review results in any changes to the Patient/Resident/Client Goals of Care, a new form must be completed.

PROVIDE COPY OF COMPLETED FORM TO PATIENT/RESIDENT/CLIENT OR SUBSTITUTE DECISION MAKER

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Where will I find the ACP?

• Filed behind the designated tab / section in the patient’s health record

• The health care directive and the ACP will be noted on the patient’s care plan / kardex

• Client’s home (Erik kit on fridge) • Home Care Nursing client file (behind nursing

care plan)

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ERIK (Emergency Response

Information Kit)

• Completed kits have a Health Information Form including name, address, health card numbers, next of kin, family physician, medical history, allergies and medications.

• The kit also contains a health care directive and organ donor card

ACP Goals of Care must be reviewed:

on each admission

when there is an unanticipated significant improvement or deterioration in clinical status

on or shortly after transfer to another facility (ensure copy of ACP form accompanies patient)

at the request of the patient or substitute decision maker

at the request of the health care team annually, at minimum

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References

College of physicians and surgeons, (n.d.). Withholding and withdrawing life- sustaining treatment. no. 1602. Retrieved from www.cpsm.mb.ca/statements/st1602.pdf

College of registered nurses, (2009). Standards of practice for registered nurses. Retrieved from cms.tng-secure.com/file_download.php?fFile_id=140

Government of Manitoba, health care directives, (n.d.). Health care directives, also known as the “living Wills”. Retrieved from www.gov.mb.ca/health/livingwill.html

Medical education division, (2007). Nursing fundamentals brookside associates. Retrieved from: www.brooksidepress.org/products/nursing_Fundamentals_1/lesson_1_section_2.htm

Psychiatric nursing : open access articles on mental health. (2011). Therapeutic communication in psychiatric nursing. Retrieved from: nursingplanet.com/pn/therapeutic_communication.html

Wrha advance care planning goals of care 110.000.200

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