©gundersen lutheran medical foundation sharing your wishes advance care planning facilitator course...

Gundersen Lutheran Medical Foundation Sharing Your Wishes Advance Care Planning Facilitator Course GCC September 2006

Gundersen Lutheran Medical Foundation Advance Care Planning Advance Care Planning Planning ahead for your last phase of life or for an unexpected event, leaving you unable to communicate. Planning ahead for your last phase of life or for an unexpected event, leaving you unable to communicate.

Gundersen Lutheran Medical Foundation SHARING YOUR WISHES GRANT This project is made possible by a grant from the Community Health Foundation of Western and Central New York. The Community Health Foundation is a non-profit private Foundation whose mission is to improve the health and healthcare of the people of Western and Central New York. This project is made possible by a grant from the Community Health Foundation of Western and Central New York. The Community Health Foundation is a non-profit private Foundation whose mission is to improve the health and healthcare of the people of Western and Central New York. Awarded to the Genesee County Long Term Care Task Force.Awarded to the Genesee County Long Term Care Task Force. Initial 2 year initiative with potential for 3rd year.Initial 2 year initiative with potential for 3rd year. Six (6) surrounding counties involved.Six (6) surrounding counties involved. Targets frail elders and their caregivers.Targets frail elders and their caregivers.

Gundersen Lutheran Medical Foundation The goal of the project: Increase awareness in our community about Advance Care Planning Using a holistic approach. Availability of care options and services Importance of health care decision making Stimulate communication Family Health care providers, Legal and spiritual advisors Strengthen our system Process to access long term care services is clear and accurate. To complete and effectively use advance care planning documents

Gundersen Lutheran Medical Foundation SHARING YOUR WISHES Objectives for Nursing Students SHARING YOUR WISHES Objectives for Nursing Students Become familiar with the advance care planning processBecome familiar with the advance care planning process Become familiar with the care options and services available to seniors and where to access informationBecome familiar with the care options and services available to seniors and where to access information Complete the Advance Care Planning Facilitator courseComplete the Advance Care Planning Facilitator course Complete a presentation on advance care planning to a group within our communityComplete a presentation on advance care planning to a group within our community Complete an ACP session with an individual and their loved onesComplete an ACP session with an individual and their loved ones

Gundersen Lutheran Medical Foundation Advance Care Planning Facilitator Course Objective To provide the facilitator with the necessary skills to assist an individual and their loved ones through the advance care planning process, which includes long term care needs and healthcare decisions. To provide the facilitator with the necessary skills to assist an individual and their loved ones through the advance care planning process, which includes long term care needs and healthcare decisions.

Gundersen Lutheran Medical Foundation Participants will be able to: Facilitate ACP for individuals and small groupsFacilitate ACP for individuals and small groups Help complete written advance directivesHelp complete written advance directives Make presentations to groups about ACPMake presentations to groups about ACP

Gundersen Lutheran Medical Foundation Group Exercise 1.) What does quality of life mean to you? 2.)What does heroics mean to you? Please take a few moments to answer these 2 questions

Gundersen Lutheran Medical Foundation

Session 1 From Advance Directives to Advance Care Planning Gundersen Lutheran/ Respecting Choices Advance Care Planning ModelGundersen Lutheran/ Respecting Choices Advance Care Planning Model How do we get from Advance Directives to Advance Care Planning?How do we get from Advance Directives to Advance Care Planning?

Gundersen Lutheran Medical Foundation Respecting Choices An Advance Care Planning System That Works Linking the Patient, Family, Provider and Community Linda Briggs, RN, MSN, MA Assistant Director, Respecting Choices & Ethics Consultant

Gundersen Lutheran Medical Foundation The Success in La Crosse Suggests What is Possible The team approach to ACP: Collaboration by major health organizations in 1991Collaboration by major health organizations in 1991 Components:Components: Multiprofessional approach and training Multimodal community education Organization & community policies and practices Patients were routinely approached about and assisted with ACP

Gundersen Lutheran Medical Foundation Gundersen Lutheran Respecting Choices After 2 years of full implementation the project had significant impact on end-of-life planning and decision making.After 2 years of full implementation the project had significant impact on end-of-life planning and decision making. Of 540 adult deaths studied from April 1995- March Of 540 adult deaths studied from April 1995- March 1996 1996 -85% had written ADs. -85% had written ADs. -96% had advance directives in their medical file. -96% had advance directives in their medical file. -98% had evidence that wishes were followed as -98% had evidence that wishes were followed as death neared death neared Patients with AD: Patients with AD: - were more likely to be admitted to long term care - were more likely to be admitted to long term care (65% vs.31%)& Hospice (29% vs. 11%) (65% vs.31%)& Hospice (29% vs. 11%) -were less likely to die in the hospital -were less likely to die in the hospital (31% vs. 68%) (31% vs. 68%)

Gundersen Lutheran Medical Foundation How do we get from Advance Directives to Advance Care Planning? A cultural change will be requiredA cultural change will be required Organizational & community engagementOrganizational & community engagement Commitment to learning new skills and practicesCommitment to learning new skills and practices Development of new standards of practiceDevelopment of new standards of practice

Gundersen Lutheran Medical Foundation A statement from the Gundersen Lutheran model (the developers of Respecting Choices): Gundersen Lutheran believes if incorporated as a routine component of care with multiple professionals taking responsibility for education and counseling, early in the course of an illness (or ones life), advance care planning can truly become a process and not an isolated event or signature on a document. The challenge is to assist professionals ( and the people in our community) in gaining the necessary knowledge and skills to attain competency in advance care planning facilitation. Gundersen Lutheran believes if incorporated as a routine component of care with multiple professionals taking responsibility for education and counseling, early in the course of an illness (or ones life), advance care planning can truly become a process and not an isolated event or signature on a document. The challenge is to assist professionals ( and the people in our community) in gaining the necessary knowledge and skills to attain competency in advance care planning facilitation.

Gundersen Lutheran Medical FoundationSummary Sharing Your Wishes is an important initiative to increase public awareness about the ACP process, increase communication between elders and their loved ones & medical providers, and to strengthen our system to ensure a persons health care wishes are honored.Sharing Your Wishes is an important initiative to increase public awareness about the ACP process, increase communication between elders and their loved ones & medical providers, and to strengthen our system to ensure a persons health care wishes are honored. ACP has proved to be successful in many other communities.ACP has proved to be successful in many other communities. To get from Advance Directives to Advance Care Planning our community requires a cultural change with a commitment to learn new skills and develop new practices.To get from Advance Directives to Advance Care Planning our community requires a cultural change with a commitment to learn new skills and develop new practices.

Gundersen Lutheran Medical Foundation Session 2 Services and Care Options for Seniors in Genesee county Office for the AgingOffice for the Aging Care Options for SeniorsCare Options for Seniors

Gundersen Lutheran Medical Foundation Genesee County Office for the Aging Provides a variety of programs and services to all county residents who are 60 years of age and older Provides a variety of programs and services to all county residents who are 60 years of age and older 343-1611 343-1611 Monday Friday Monday Friday 8:30- 5 p.m.

Gundersen Lutheran Medical Foundation Genesee County Office for the Aging Long Term Care Services Genesee County Office for the Aging Long Term Care Services Nutrition: Meals on Wheels, Senior meal programs, nutrition counselingNutrition: Meals on Wheels, Senior meal programs, nutrition counseling Medical TransportationMedical Transportation Nursing Home CounselingNursing Home Counseling Home Care/ EISEPHome Care/ EISEP Assistance with applications for benefits Ombudsman program Assessments for seniors with financial needs

Gundersen Lutheran Medical Foundation Genesee County Office for the Aging Information and referrals Housing for SeniorsHousing for Seniors Adult Day CareAdult Day Care Home Health CareHome Health Care RespiteRespite Nursing HomesNursing Homes Personal Emergency Response SystemPersonal Emergency Response System Medical ServicesMedical Services Social Security Benefits Weatherization referrals Food stamps & Medicaid Alzheimers services

Gundersen Lutheran Medical Foundation Genesee County Office for the Aging Information and Services CounselingCounseling Discount servicesDiscount services Legal Services: POA, Living Will, HCP, Medicaid eligibility, Long Term Care Insurance, Financial PlanningLegal Services: POA, Living Will, HCP, Medicaid eligibility, Long Term Care Insurance, Financial Planning Volunteer Placement- RSVPVolunteer Placement- RSVP Recreation programs and activitiesRecreation programs and activities Caregiver Resource Center: counseling and support groups Community Education Newsletters Tax Preparation Notary services Photocopying Voter registration Site

Gundersen Lutheran Medical Foundation CARE OPTIONS FOR SENIORS IN GENESEE COUNTY www.co.genesee.ny.us from the main menu select :www.co.genesee.ny.us Care Options for Seniors Your Link to Services in Genesee County

Gundersen Lutheran Medical Foundation Summary The Genesee county Office For the Aging has many services and programs for adults 60 years of age or older.The Genesee county Office For the Aging has many services and programs for adults 60 years of age or older.

Gundersen Lutheran Medical Foundation The Important Role of an Advance Care Planning Facilitator Session 3 ACP Facilitator definition ACP Facilitator qualifications ACP Facilitator roles and responsibilities

Gundersen Lutheran Medical Foundation Advance Care Planning Facilitator A person who is able to guide others to understand through the advance care planning process. This includes reflecting on life values and goals, examining support services, and understanding the impact of future healthcare decisions.

Gundersen Lutheran Medical Foundation Facilitate To Guide To Guide To Help To Help To Assist To Assist To Advance To Advance

Gundersen Lutheran Medical Foundation Advance Care Planning Facilitator Qualifications Can come from any background or experience with a desire to enhance the quality of life for seniors.Can come from any background or experience with a desire to enhance the quality of life for seniors. Have good communication skills and the ability to be an active listener.Have good communication skills and the ability to be an active listener. Be able to discuss sensitive issues.Be able to discuss sensitive issues. Have the ability to respect cultural, spiritual and personal differences.Have the ability to respect cultural, spiritual and personal differences. Be able to remain non-judgmental, non-prying and to respect an individuals choices.Be able to remain non-judgmental, non-prying and to respect an individuals choices. Maintain confidentialityMaintain confidentiality Complete the Advance Care Planning facilitator training programComplete the Advance Care Planning facilitator training program

Gundersen Lutheran Medical Foundation Advance Care Planning Facilitator Role and responsibilities Be knowledgeable in the advance care planning process and services available to seniorsBe knowledgeable in the advance care planning process and services available to seniors Initiate advance care planning discussionsInitiate advance care planning discussions Provide education an the advance care planning processProvide education an the advance care planning process Facilitate discussions of advance care planning with seniors and their loved ones.Facilitate discussions of advance care planning with seniors and their loved ones. Assist seniors in the completion of advance directivesAssist seniors in the completion of advance directives Make referrals for other services when necessaryMake referrals for other services when necessary

Gundersen Lutheran Medical Foundation Summary ACP facilitators must have good communication skills and the abilities to discuss sensitive issues while respecting cultural, spiritual & personal differences.ACP facilitators must have good communication skills and the abilities to discuss sensitive issues while respecting cultural, spiritual & personal differences. ACP facilitators need to be knowledgeable in the ACP process, services available to seniors, and have the abilities to initiate and facilitate ACP with seniorsACP facilitators need to be knowledgeable in the ACP process, services available to seniors, and have the abilities to initiate and facilitate ACP with seniors

Gundersen Lutheran Medical Foundation You can make a difference in the life of a senior by becoming a facilitator. by becoming a facilitator.

Gundersen Lutheran Medical Foundation Session 4 Advance Care planning: Understanding the concept How can we assist people?How can we assist people? Why is it necessary?Why is it necessary? What are the benefits?What are the benefits? For seniors For seniors For loved ones For loved ones For medical providers For medical providers For the work place For the work place Why is it avoided? Why do we often fail? When is it successful? Local findings

Gundersen Lutheran Medical Foundation Advance Care Planning A process of understanding, reflecting and communicating preferences for future care, including care options and health care decisions.A process of understanding, reflecting and communicating preferences for future care, including care options and health care decisions.

Gundersen Lutheran Medical Foundation Assisting with Advance Care Planning Assisting with Advance Care Planning Encouraging people to review their wishes and expectations with their loved ones, health care agent, physicians, lawyers and spiritual advisors.Encouraging people to review their wishes and expectations with their loved ones, health care agent, physicians, lawyers and spiritual advisors. Assisting people in completing the New York State Health Care Proxy form, Living Will, DNR and Non-hospital DNR forms.Assisting people in completing the New York State Health Care Proxy form, Living Will, DNR and Non-hospital DNR forms. Instructing seniors to review and updating these forms periodically and after life changing events.Instructing seniors to review and updating these forms periodically and after life changing events. Emphasizing the importance of conducting ongoing conversations about their wishes and expectations with their loved ones, health care agent, physicians, lawyers and spiritual advisors.Emphasizing the importance of conducting ongoing conversations about their wishes and expectations with their loved ones, health care agent, physicians, lawyers and spiritual advisors.

Gundersen Lutheran Medical Foundation ADVANCE CARE PLANNING Why is it necessary? ADVANCE CARE PLANNING Why is it necessary? Americans will live longer and healthier lives than ever before. Life expectancy in one century has gone from 47 to 75

Gundersen Lutheran Medical Foundation Advance care planning :Why is it necessary? Most people will experience chronic illness or disability with complex health issues in the last phase of their lives: complex health issues in the last phase of their lives: *8 out of 10 seniors 65 or older have at least 1 *8 out of 10 seniors 65 or older have at least 1 chronic condition chronic condition *5 out of 10 have at least 2 chronic conditions *5 out of 10 have at least 2 chronic conditions *1 out of 2 people may require long term care *1 out of 2 people may require long term care services services *1 out of 2 people may be unable to make decisions *1 out of 2 people may be unable to make decisions for themselves during their dying process for themselves during their dying process

Gundersen Lutheran Medical Foundation Advance care planning :Why is it necessary? Multiple changes and advancements in medical technology, extending life. Health professionals typically treat when uncertain. Most of us will die under the care of health professionals.

Gundersen Lutheran Medical Foundation Advance care planning: Why is it necessary ? To ensure clinical care is consistent with the individuals wishes. Multiple changes have occurred in the family structure. Loved ones have a significant chance of not knowing a persons views without discussion. To reduce an individuals concern regarding possible burden placed on family and others.

Gundersen Lutheran Medical Foundation Advance Care Planning why is it necessary? Currently under New York State law, no one, not even a family member, has the legal right to make health care decisions for a person if they become incapacitated.Currently under New York State law, no one, not even a family member, has the legal right to make health care decisions for a person if they become incapacitated. Less than 25% of Americans have created some form of plan outlining how they wish to be treated in the last phase of their life.Less than 25% of Americans have created some form of plan outlining how they wish to be treated in the last phase of their life.

Gundersen Lutheran Medical Foundation Why is it necessary? How the Majority of Americans Die How the Majority of Americans Wish to Die Over 75% 80% Patricia Bomba, M.D. Vice President & Medical Director, Geriatrics

Gundersen Lutheran Medical Foundation Advance care planning affects many in our community 2000 Census County residents age sixty plus: 11,095 (18.5% of total pop, 3.2% increase from 1990) People 85+ increased from 860 to 1,101 (28% increase) By 2015: People 85+ to increase to almost 1,400 NYS Office for Aging Project 2015

Gundersen Lutheran Medical Foundation The Aging Today and Tomorrow Source: Policy Committee White House Conference on Aging -- July 14, 2004

Gundersen Lutheran Medical Foundation Advance care planning what are the benefits? Advance care planning what are the benefits? For the patient.For the patient. For the family/loved onesFor the family/loved ones For medical providersFor medical providers For the work placeFor the work place

Gundersen Lutheran Medical Foundation Advance Care Planning: Benefits Maintain Control Achieve Peace of Mind Can make difficult transitions easier Assure wishes are honored when they are unable to communicate them. For the senior, frail elder.

Gundersen Lutheran Medical Foundation Advance Care Planning: Benefits for family and loved ones Empowers and guides family/significant others in making crucial health care decisions for a loved one.Empowers and guides family/significant others in making crucial health care decisions for a loved one. Helps avoid family conflict over treatment options.Helps avoid family conflict over treatment options. Aids in coping with grief if they are clear that they have followed the wishes of their loved one.Aids in coping with grief if they are clear that they have followed the wishes of their loved one.

Gundersen Lutheran Medical Foundation Advance Care Planning: Benefits for the medical providers Improves quality care by matching provided treatment with an individuals preferences and decreasing utilization of acute care services.Improves quality care by matching provided treatment with an individuals preferences and decreasing utilization of acute care services. Decreases unnecessary stress on staff.Decreases unnecessary stress on staff. Reduces the possibility of litigation.Reduces the possibility of litigation.

Gundersen Lutheran Medical Foundation Advance Care Planning: Benefits for the medical providers Guides physicians in decision making.Guides physicians in decision making. Reduces the amount of time in crisis management for the final phase of life decisions.Reduces the amount of time in crisis management for the final phase of life decisions. Reduces time spent in lengthy, repeated family care conferences exploring whether to continue or forgo medical treatment.Reduces time spent in lengthy, repeated family care conferences exploring whether to continue or forgo medical treatment.

Gundersen Lutheran Medical Foundation Advance Care Planning: Benefits for the work place Reduce employee absenteeism Nationally, 1 in 4 employees is involved with Nationally, 1 in 4 employees is involved with caring for an older adult caring for an older adult

Gundersen Lutheran Medical Foundation ACP: Why is it avoided ? ACP: Why is it avoided ? Many have not considered the importance of ACP. Many have not considered the importance of ACP. Lack of information or unsure where to get information. Lack of information or unsure where to get information. It can be very personal and may elicit strong emotional reactions. It can be very personal and may elicit strong emotional reactions. It may be unclear how to start the conversation. It may be unclear how to start the conversation. It may raise issues that are difficult to resolve. It may raise issues that are difficult to resolve. Many believe it is for elders or the sick. Many believe it is for elders or the sick. May cause worry to loved ones. May cause worry to loved ones.

Gundersen Lutheran Medical Foundation Why is ACP sometimes avoided by health care professionals? Lack of professional, training, skill and confidence. Lack of professional, training, skill and confidence. Believe they are adequately addressing ACP needs of their pt. Believe they are adequately addressing ACP needs of their pt. Focused on completion of AD. Focused on completion of AD. Perceived lack of time. Perceived lack of time. Lack of reimbursement. Lack of reimbursement. No developed system. No developed system.

Gundersen Lutheran Medical Foundation Ways we often fail: People lack knowledge and understanding of services available to them. People lack knowledge and understanding of services available to them. Peoples values and preferences are not known. Peoples values and preferences are not known. Written plans do not reflect a persons preferences. Written plans do not reflect a persons preferences. Written plans are often not available. Written plans are often not available. Written plans are not clear or are irrelevant. Written plans are not clear or are irrelevant.

Gundersen Lutheran Medical Foundation Advance Care Planning is successful when: Future options are understood. Future options are understood. Options are considered based on the persons values Options are considered based on the persons values and goals. and goals. Choices are discussed with loved ones and medical Choices are discussed with loved ones and medical providers before a crisis. providers before a crisis. A plan is formulated and supported by loved ones. A plan is formulated and supported by loved ones. Health care documents are accessible. Health care documents are accessible.

Gundersen Lutheran Medical Foundation Local Findings In Genesee County 4 community conversations with about 80 seniors were conducted in July/August 2005, the results: KNOWLEDGE DEFICIT where to go for information about care options and services available to seniors.where to go for information about care options and services available to seniors. terminology and definitions of advance directives terminology and definitions of advance directives advance health care planning as a process not a piece of paperadvance health care planning as a process not a piece of paper proper completion of forms/documentsproper completion of forms/documents need to update forms periodicallyneed to update forms periodically

Gundersen Lutheran Medical Foundation Local Findings LACK OF COMMUNICATION between family, loved ones, spiritual advisors and person completing forms.between family, loved ones, spiritual advisors and person completing forms. between physicians and person completing formsbetween physicians and person completing forms - 70% feel it would not be difficult to talk with their - 70% feel it would not be difficult to talk with their physician about their wishes for end of life. physician about their wishes for end of life. -80% had not talked with their physician about -80% had not talked with their physician about end of life care. end of life care.

Gundersen Lutheran Medical Foundation Local Findings NEED TO EDUCATE ABOUT : Services available to seniors in Genesee countyServices available to seniors in Genesee county Terms and definitions of advance directives Terms and definitions of advance directives Advance care planning as a processAdvance care planning as a process Proper completion of forms Proper completion of forms Need to update forms Need to update forms How to have conversations with families, loved ones, spiritual advisors, physicians and medical providers. How to have conversations with families, loved ones, spiritual advisors, physicians and medical providers.

Gundersen Lutheran Medical Foundation Ways facilitators can improve the quality of life of people in our community Ways facilitators can improve the quality of life of people in our community Encouraging ACP as an ongoing process not a one time event.Encouraging ACP as an ongoing process not a one time event. Understanding the services and care options available for seniors in Genesee County, referring individuals as appropriate.Understanding the services and care options available for seniors in Genesee County, referring individuals as appropriate. Assisting an individual to become more informed about their health & wellness, their diagnosis & prognosis and the benefits & burdens of treatments.Assisting an individual to become more informed about their health & wellness, their diagnosis & prognosis and the benefits & burdens of treatments. Guiding an individual to explore, clarify and document their values, beliefs, goals and wishes. Including appointing a Health Care Agent.Guiding an individual to explore, clarify and document their values, beliefs, goals and wishes. Including appointing a Health Care Agent. Informing seniors of the importance of taking control of their own. lives. Informing seniors of the importance of taking control of their own. lives.

Gundersen Lutheran Medical Foundation Summary ACP is an ongoing process that includes understanding, reflecting, discussing and formulating a plan.ACP is an ongoing process that includes understanding, reflecting, discussing and formulating a plan. ACP effects everyone in our community.ACP effects everyone in our community. ACP provides many benefits to the individual, their loved ones, medical providers and spiritual leaders.ACP provides many benefits to the individual, their loved ones, medical providers and spiritual leaders. ACP is successful when care options are understood & considered based on a persons values and goals, a plan is developed and supported by loved ones, and the healthcare documents are accessible.ACP is successful when care options are understood & considered based on a persons values and goals, a plan is developed and supported by loved ones, and the healthcare documents are accessible.

Gundersen Lutheran Medical Foundation Session 5 Advance Directives: Understanding the language and tools Types of ADTypes of AD Living WillLiving Will Power of AttorneyPower of Attorney Health Care AgentHealth Care Agent Health Care ProxyHealth Care Proxy Non-hospital Do Not ResuscitateNon-hospital Do Not Resuscitate MOLST formMOLST form

Gundersen Lutheran Medical Foundation An Advance Directive is... a plan, indicating preferences for future health care decisions if a person becomes unable to speak for themselves.

Gundersen Lutheran Medical Foundation Types of Advance Directives I.Oral II.Written A. Formal (signed, dated, witnessed) 1. Meets statutory requirements B. Informal 1. Physicians note 2. Personal letter

Gundersen Lutheran Medical Foundation Advance Directives can be changed or revoked at any time either in writing or verbally. An Advance Directive only takes effect when a person becomes unable to make their own decision due to illness or injury. When can an AD be changed?

Gundersen Lutheran Medical Foundation Session 5 Making Choices Video and discussion about the importance of Advance Care Planning

Gundersen Lutheran Medical Foundation Session 6 An Overview of Law, Ethics & Medicine, related to Advance Health Care Planning Right to Refuse Medical TreatmentRight to Refuse Medical Treatment Patient Self- Determination ActPatient Self- Determination Act Ethical basis for ACPEthical basis for ACP Life-Sustaining Treatments *Benefits and Burdens of Treatments *CPR, including outcomes *Nutritional Support *Hydration Comfort Care

Gundersen Lutheran Medical Foundation Right to refuse medical treatment Competent adults have a right to refuse medical/surgical treatment at any time. Competent adults have a right to refuse medical/surgical treatment at any time. This right continues even if the person is This right continues even if the person is incapable. incapable. The most that a state can require is clear and convincing evidence of an adults choices. The most that a state can require is clear and convincing evidence of an adults choices.

Gundersen Lutheran Medical Foundation Patient Self-Determination Act A federal statute that requires health organizations: -To ask adults about advance directives at admission. -To provide written information about rights to refuse treatment and to have an AD. -To provide education to staff and community about ADs.

Gundersen Lutheran Medical Foundation Ethical Basis for ACP Successful ACP promotes: -Respect of patients values and wishes. -Respect for right to self-determination.

Gundersen Lutheran Medical Foundation Decisions Should be Guided by: -Determining the persons goalsboth medical and non-medical. -Considering the benefits and burdens for the person of particular options or choices.

Gundersen Lutheran Medical Foundation Advance Health Care Planning: creates an environment of shared decision-making among individuals, loved ones, and health professionals.

Gundersen Lutheran Medical Foundation Life-sustaining treatments: Any treatment or intervention that is used to sustain or prolong life. Any treatment or intervention that is used to sustain or prolong life.

Gundersen Lutheran Medical Foundation A treatment may be beneficial if it is... -Effective in prolonging life. -Effective in restoring/maintaining function. -Promotes goals/values of patient. -Consistent with religious/cultural beliefs.

Gundersen Lutheran Medical Foundation A treatment may be considered burdensome if... Results in more or intolerable pain. Results in more or intolerable pain. Damages the body image or function. Damages the body image or function. Psychologically harmful. Psychologically harmful. Does not conform to their quality of life. Does not conform to their quality of life. Cost is unacceptable. Cost is unacceptable.

Gundersen Lutheran Medical Foundation Choices about life-sustaining treatments When to start. When to start. When to forgo (may choose limited time trials of treatment). When to forgo (may choose limited time trials of treatment). How and when to maintain comfort. How and when to maintain comfort.

Gundersen Lutheran Medical Foundation Mixed Management Allows for choices to extend life as well as choices that prepare for death and provide comfort.

Gundersen Lutheran Medical Foundation Understanding the potential goals, benefits/burdens, and outcomes for life-sustaining treatments is important. CPR CPR Intubation /ventilation Intubation /ventilation Nutritional support Nutritional support IV hydration IV hydration

Gundersen Lutheran Medical Foundation What is Resuscitation? Life-Sustaining Treatments What is Resuscitation? Life-Sustaining Treatments If your heart stops: Electrical shock to the heart and injection of medications. If your breathing stops: mechanical ventilation. Common Life-Sustaining TreatmentsCommon Life-Sustaining Treatments CPR: Group of treatments used when someones heart or breathing stops Mechanical Ventilation: Use of a machine attached to a tube inserted through nose or mouth that forces air into the lungs Artificial Hydration and Nutrition: Artificial means of giving food or water

Gundersen Lutheran Medical Foundation CPR Outcomes The success rate of CPR is often thought to be much higher than it actually is. The success rate of CPR is often thought to be much higher than it actually is. Approximately 15% of hospitalized patients survive and return to previous function. Approximately 15% of hospitalized patients survive and return to previous function. Success rates in some populations are much lower, e.g., in long term care, advanced cancer, the success rate is < 2%. Success rates in some populations are much lower, e.g., in long term care, advanced cancer, the success rate is < 2%.

Gundersen Lutheran Medical Foundation CPR Outcomes For those who do survive the CPR attempt, complications include:For those who do survive the CPR attempt, complications include: Prolonged ICU stay on mechanical ventilation Decreased mental functioning Rib fractures

Gundersen Lutheran Medical Foundation Artificial Nutrition and Hydration When a person can no longer take food or fluid by mouth, a feeding tube can sometimes be used.When a person can no longer take food or fluid by mouth, a feeding tube can sometimes be used. -Nasogastric tube -Nasogastric tube -Gastrostomy tube -Gastrostomy tube Or intravenously nutrition can be administered.Or intravenously nutrition can be administered. -Total Parenteral Nutrition -Total Parenteral Nutrition

Gundersen Lutheran Medical Foundation Points about Nutritional Support Nutrition delivered by tubes is a medical treatment Nutrition delivered by tubes is a medical treatment With a terminal illness, the body often can not process food normally and forcing nutrition will not prolong life. With a terminal illness, the body often can not process food normally and forcing nutrition will not prolong life. Naturally in the dying process there is decreased appetite and thirst. Naturally in the dying process there is decreased appetite and thirst. The word starvation is an emotionally charged word that does not describe the cause of death. The word starvation is an emotionally charged word that does not describe the cause of death.

Gundersen Lutheran Medical Foundation Comfort Care No aggressive or life prolonging treatments, symptom control measures only.No aggressive or life prolonging treatments, symptom control measures only. Providing optimal pain control and comfort measures.Providing optimal pain control and comfort measures. Providing physical, emotional and spiritual support to the terminally ill person and their family.Providing physical, emotional and spiritual support to the terminally ill person and their family. Allowing natural death to occur.Allowing natural death to occur. Comfort Care does not mean dont treat ! Comfort Care does not mean dont treat !

Gundersen Lutheran Medical Foundation Summary All Adults have a right to refuse treatments.All Adults have a right to refuse treatments. Decisions for care options and treatments should be guided by a persons preferences and goals, while considering the benefits and burdens of treatments.Decisions for care options and treatments should be guided by a persons preferences and goals, while considering the benefits and burdens of treatments. Life sustaining treatment is any treatment used to prolong life.Life sustaining treatment is any treatment used to prolong life. Decisions can be made about when to begin and forgo treatment & when to provide comfort care.Decisions can be made about when to begin and forgo treatment & when to provide comfort care.

Gundersen Lutheran Medical Foundation Session 7 Problem Solving Scenarios Please break up into groups of 3

Gundersen Lutheran Medical FoundationSession 8Advance Care Planning: Facilitating the Process Basic skills at initiating ACP discussions Basic skills at initiating ACP discussions Facilitation skills with different groups:Facilitation skills with different groups: - the healthy adult - the healthy adult the adult with incurable, progressive disease the adult expected to die within 12 months or those in long term care those in long term care the adult with new, serious conditions

Gundersen Lutheran Medical Foundation Basic Skills at Initiating ACP Affirm relationship; support, timeAffirm relationship; support, time Introduce the conceptIntroduce the concept Explain ACPExplain ACP Explain ACP Assesses motivation, knowledge, beliefs Encourage reflection and discussion

Gundersen Lutheran Medical Foundation Basic Skills at Initiating ACP Explore statements, preferencesExplore statements, preferences Encourage loved ones involvementEncourage loved ones involvement Assist in choosing an appropriate agentAssist in choosing an appropriate agent Provide information, worksheets Make referrals Develop a follow up plan

Gundersen Lutheran Medical Foundation Introduce the Concept Id like to give you some information that you can take with you to get started thinking about the kinds of choices you might want to make for your future care.

Gundersen Lutheran Medical Foundation Explain Advance Care Planning This is called Advance Care Planning and it is a good idea to take some time to understand whats involved, think about your choices, what your goals and values are and then discuss them with loved ones and others as needed. If you have questions about your medical condition, you can talk with your MD.

Gundersen Lutheran Medical Foundation Encourage Reflection and Discussion If you want to complete a document now, we can have someone help you. However, we often encourage people to take these materials home, review them with loved ones and begin to discuss the issues, choices and questions you may have.

Gundersen Lutheran Medical Foundation Develop a Follow-up Plan When you and your loved ones are ready to learn more or complete a written plan, please call me and we will schedule a time that I can assist you in any way you need.

Gundersen Lutheran Medical Foundation Skills to Engage people in Advance Care Planning Discussions

Gundersen Lutheran Medical Foundation Eliciting the persons perspective Take time to listen Take time to listen Ask for persons story about end-of-life care Ask for persons story about end-of-life care Attempt to determine the persons current health status and their understanding of it. Attempt to determine the persons current health status and their understanding of it. Start with a focus on goals and what it might mean to live well at this point or in future circumstances Start with a focus on goals and what it might mean to live well at this point or in future circumstances

Gundersen Lutheran Medical Foundation Before Developing a Plan, Address: Expressed fears Expressed fears Misunderstandings about basic facts or processes Misunderstandings about basic facts or processes Gaps in knowledge Gaps in knowledge

Gundersen Lutheran Medical Foundation Next, Explore and Clarify What do you value most about your physical and mental well being?What do you value most about your physical and mental well being? What gives your life meaning and purpose?What gives your life meaning and purpose? What are your religious or spiritual beliefs?What are your religious or spiritual beliefs? What are your hopes and wishes for the final phase of your life? What are your hopes and wishes for the final phase of your life? Have you thought about living arrangements as you age and become more frail?Have you thought about living arrangements as you age and become more frail?

Gundersen Lutheran Medical Foundation Common Misunderstood Expressions Common Misunderstood Expressions No Heroics No Heroics Dont keep me alive if I am a vegetable. Dont keep me alive if I am a vegetable. Dont keep me alive on machines. Dont keep me alive on machines. If I am terminal, let me go. If I am terminal, let me go.

Gundersen Lutheran Medical Foundation Explain qualifications for surrogate Willing and available. Willing and available. values and preferences. values and preferences. Understands what is important to you.Understands what is important to you. Will talk about sensitive issues now.Will talk about sensitive issues now. Will listen to your wishes.Will listen to your wishes. Can separate his/her feelings from yours.Can separate his/her feelings from yours. Willing to speak on your behalf.Willing to speak on your behalf. Would honor and act on your wishes.Would honor and act on your wishes. Able to handle challenges during difficult times.Able to handle challenges during difficult times.

Gundersen Lutheran Medical Foundation Facilitation Skills with Different Groups of Adults Basic skills with all adultsBasic skills with all adults Adults with chronic, progressive diseaseAdults with chronic, progressive disease Adults expected to die within 12 months or those in long-term careAdults expected to die within 12 months or those in long-term care

Gundersen Lutheran Medical Foundation What to discuss with all adults Are you familiar with the different long term care services available to you? Are you familiar with the different long term care services available to you? Do you know where to go for information about the services? Do you know where to go for information about the services?

Gundersen Lutheran Medical Foundation What to discuss with all adults Who would you want to make decisions if you couldnt? Who would you want to make decisions if you couldnt? What would be the goals of treatment if you permanently lost the ability to know who you were, who you were with, or where you were? What would be the goals of treatment if you permanently lost the ability to know who you were, who you were with, or where you were? Do you have any religious, personal, or cultural views that would affect treatment choices? Do you have any religious, personal, or cultural views that would affect treatment choices?

Gundersen Lutheran Medical Foundation What to discuss with adults with a chronic, progressive illness The same issues as a healthy adult, plus Goals and benefits/burdens of initiating/forgoing treatment most likely needed to attempt to sustain life Goals and benefits/burdens of initiating/forgoing treatment most likely needed to attempt to sustain life Desires for comfort care for specific illness Desires for comfort care for specific illness

Gundersen Lutheran Medical Foundation What to discuss with adults who may die in the next 12 months The same issues as a healthy adult as well as an adult with a chronic, progressive illness, plus The same issues as a healthy adult as well as an adult with a chronic, progressive illness, plus Review the persons medical and non-medical goals. Review the persons medical and non-medical goals. Make decisions about CPR, hospitalization, nutritional support, etc, if not already made. Make decisions about CPR, hospitalization, nutritional support, etc, if not already made. Review options for comfort care and life closure. Review options for comfort care and life closure.

Gundersen Lutheran Medical Foundation What to Discuss with all Adults: Explore What is Most Important and How They Want to Receive Care What makes your day worthwhile?What makes your day worthwhile? What experiences are most important for you to live wellWhat experiences are most important for you to live well at this time and in the future of your life? at this time and in the future of your life? How does your faith impact your health care decision making?How does your faith impact your health care decision making? What gives you strength or sustains you in difficult times?What gives you strength or sustains you in difficult times?

Gundersen Lutheran Medical Foundation Explore What is Most Important and How They Want to Receive Care What fears or worries do you have about your illness or medical care?What fears or worries do you have about your illness or medical care? Have the illnesses or deaths of loved ones influencedHave the illnesses or deaths of loved ones influenced your view of the medical system? your view of the medical system? What are your goals for care and where would you like to receive care?What are your goals for care and where would you like to receive care? Are there circumstances under which you would refuseAre there circumstances under which you would refuse or discontinue treatment that might prolong your life? or discontinue treatment that might prolong your life?

Gundersen Lutheran Medical Foundation Some Other Things to consider in Pre-Planning: Completion of a Will: a legal document used to divide assets and property after death.Completion of a Will: a legal document used to divide assets and property after death. Organ donation.Organ donation. Burial arrangements.Burial arrangements.

Gundersen Lutheran Medical Foundation Summary Skills at initiating ACP conversations must be learned and incorporated as routine care. Skills at initiating ACP conversations must be learned and incorporated as routine care. Different facilitation skills are required for different groups of adults. Different facilitation skills are required for different groups of adults. Facilitation skills require practice and experience to develop. Facilitation skills require practice and experience to develop.

Gundersen Lutheran Medical Foundation Session 9 Respecting Choices: The Facilitation Process with a Healthy Adult video and discussion

Gundersen Lutheran Medical Foundation Session 10 Creating an Advance Directive Communicating the Plan

Gundersen Lutheran Medical Foundation Basic Standards for Communication Written plans are best. Written plans are best. Recommend the document that best meets the needs of the individual. Recommend the document that best meets the needs of the individual. Strive for clarity, accuracy, and completeness. Strive for clarity, accuracy, and completeness. Encourage the agent and loved ones to be a part of the conversations when ever possible. Encourage the agent and loved ones to be a part of the conversations when ever possible.

Gundersen Lutheran Medical Foundation Living Wills are Limited Living Wills are Limited Only give instructions for a limited number of circumstances Only give instructions for a limited number of circumstances Often do not apply to needed decisions Often do not apply to needed decisions No surrogate to make decisions No surrogate to make decisions

Gundersen Lutheran Medical Foundation Health Care Proxys are typically best A person can make decisions with MD in real time. A person can make decisions with MD in real time. May provide a wide range of instructions. May provide a wide range of instructions. Applies to a wide range of health decisions. Applies to a wide range of health decisions.

Gundersen Lutheran Medical Foundation Statutory Requirements Review Health Care Proxy form Review Health Care Proxy form Review Living Will form Review Living Will form

Gundersen Lutheran Medical Foundation Summary Summary Assist individuals in selecting a communication plan Assist individuals in selecting a communication plan Understand/clarify terminology Understand/clarify terminology Know statutory requirements Know statutory requirements

Gundersen Lutheran Medical Foundation Current Education of health care professionals Focused on completion of advance directives Focused on completion of advance directives No developed system to practice or work No developed system to practice or work No defined responsibilities or competencies No defined responsibilities or competencies Inadequate or conflicting teaching resources Inadequate or conflicting teaching resources Little or no management or review of practice Little or no management or review of practice Studies of professionals knowledge of end-of-life issues reveal a lack of awareness of ethical & legal rulings, but also continued dissatisfaction and discomfort when placed in these situations

Gundersen Lutheran Medical Foundation The Role of the RN as an ACP Facilitator Assess the need for informationAssess the need for information Initiate conversation when cues arriveInitiate conversation when cues arrive Provide accurate information on medical condition or refer to MDProvide accurate information on medical condition or refer to MD Listen/ClarifyListen/Clarify Make appropriate referralsMake appropriate referrals Provide emotional supportProvide emotional support Communicate choicesCommunicate choices Follow organizational policiesFollow organizational policies

Gundersen Lutheran Medical Foundation Session 11 The Four Steps for Success in Advance Care Planning

Before a crisis occurs or a treatment option is considered take time to explore your: Health & wellnessHealth & wellness Diagnosis & prognosisDiagnosis & prognosis Treatment benefits & burdensTreatment benefits & burdens Options & available servicesOptions & available services

Gundersen Lutheran Medical Foundation The Four steps for success in Advance Care Planning The Four steps for success in Advance Care Planning 1. REFLECT Consider your personal values and spiritual beliefs. Think about what is important to you and how you want to receive your care. Consider your personal values and spiritual beliefs. Think about what is important to you and how you want to receive your care.

Gundersen Lutheran Medical Foundation The Four steps for success in Advance Care Planning The Four steps for success in Advance Care Planning 2. CHOOSE Select the best person to speak for you if you become unable to speak for yourself. Select the best person to speak for you if you become unable to speak for yourself.

Gundersen Lutheran Medical Foundation The Four steps for success in Advance Care Planning The Four steps for success in Advance Care Planning 3. TALK Start the conversationshare your wishes with your loved ones, health care agent, medical professionals, lawyers and spiritual advisors. Continue the conversation throughout your life. Start the conversationshare your wishes with your loved ones, health care agent, medical professionals, lawyers and spiritual advisors. Continue the conversation throughout your life.

Gundersen Lutheran Medical Foundation The Four steps for success in Advance Care Planning The Four steps for success in Advance Care Planning 4. WRITE Put your health care wishes in writing and give a copy to your loved ones, health care agent, physicians, lawyers and spiritual advisors. Keep copies on you at all times. Put your health care wishes in writing and give a copy to your loved ones, health care agent, physicians, lawyers and spiritual advisors. Keep copies on you at all times. Update the forms periodically. Update the forms periodically.

Gundersen Lutheran Medical Foundation Imagine If.SYW Vision A majority of frail elders in Genesee County knew what kind of last-phase-of-life care they wanted; Were able to talk about this with their family members and medical providers and spiritual advisors; Had their wishes clearly expressed in a legal document; The document was accessible and used to direct and guide their medical care and support services to improve their quality of life during the last years of their life.

Gundersen Lutheran Medical Foundation Conclusion Thank you for your participation! Conclusion Thank you for your participation! Questions?Questions? Comments?Comments? Please complete a course evaluationPlease complete a course evaluation A certificate of completion for this course will be mailed to you in the near future.A certificate of completion for this course will be mailed to you in the near future. Contact Cathie Plaisted at The Office for the Aging 343-1611for any questions or for literature and materials for your presentations.Contact Cathie Plaisted at The Office for the Aging 343-1611for any questions or for literature and materials for your presentations.

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Documents

availability of care

long term care needs

access long term care

nonprofit private foundation

loved ones slide

central new york

wishes grant

wishes objectives