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Pearls of Advanced Care Planning (ACP) by Mary Mueller, RN MSN APNP BC PowerPoint Presentation
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Pearls of Advanced Care Planning (ACP) by Mary Mueller, RN MSN APNP BC

Pearls of Advanced Care Planning (ACP) by Mary Mueller, RN MSN APNP BC

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Pearls of Advanced Care Planning (ACP) by Mary Mueller, RN MSN APNP BC

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  1. Pearls of Advanced Care Planning (ACP)by Mary Mueller, RN MSN APNP BC

  2. Objectives • The learner will be able to identify at least two key components of Advance Care Planning (ACP). • The learner will be able to identify three possible goals of the process of ACP in long term care. • The learner will be able to identify two vital elements of effective communication in the ACP process. • The learner will be able to apply key concepts of the ACP into day to day operations while caring for the resident and enhancing quality of care. • The learner will be able to identify at least two cultural, ethical or legal concepts that may impact effective ACP.

  3. Advanced Care Plan Process • Process of planning for the future • Directs the goals of care and establishes realistic boundaries • Assumes the right to participate in the planning of health care wishes • Personal journey based on cultural, personal and religious values, beliefs, and preferences • Trust building • Communication

  4. Components of Advanced Care Planning • Who: • Resident/Family Members/RPs • Primary Care Team (PCT) • Specialists, hospice • Spiritual leaders • How • Open ongoing honest comprehensive multidisciplinary communication • Commitment to timely accurate documentation • Establishing of appropriate goals of care • When (time, appropriateness) • Where (environment, settings)

  5. ACP as a Process of Communication • Develop process for open and ongoing interdisciplinary communication • It is not a finite process- ongoing • Encourage discussion of individual's values and preferences • Facilitate discussion of individual's understanding of the decision making process in advanced care planning based on life-to-death trajectory and the current physical and emotional state • Maintain open communication with the Primary Care Team throughout the entire process of ACP

  6. Timing for ACP Recommended times for advanced care planning discussions: • Initial assessment and/or admission • Review advance care planning status on routine assessments • When the individual has a change in condition • Change in condition that is treated in nursing facility • Change in condition associated with a hospitalization • Discussion after hospitalization,

  7. Goals of Care • To give the right care • To the right person • In the right place • At the right time • For the right reason

  8. A New Paradigm

  9. Longevity • “I want to live at all costs” • Looking for reversal of disease process • Looking for cure • Function at all costs

  10. Function • Maintain or increase function: • May give up longevity • Decrease Comfort • Must have a goal in mind • define function to be maintained • review living will

  11. Comfort • High touch—low tech • Pain management • Family • Support family tasks: reading, massage, Reiki hand positions • Proactive • In control of the death • Can orchestrate “the good death” • Hospice consideration

  12. Effective Advanced Care Planning Will yield: • Crisis avoidance • Adherence to wishes and values • Respect the right of individual to have opportunity to discuss life decisions • Opportunity to identify documentation needs to meet legal requirements (updated DPOAs, initiation of guardianships, timely activation of DPOAs, completion of Advanced Directives) • Ability to maintain ethical boundaries (futility, justice, negligence and malpractice)

  13. In Conclusion…. Evercare advocates the importance of Advance Care Planning Thank-you for your Time

  14. References • Aparanji K, Dharmarajan TS. Pause Before a Peg: A Feeding Tube may not be necessary in Every Candidate. JAMDA 2010;11(6): 453-455. • Associated Press. American are Treated, and Overtreated to Death June 28,2010. • Dunn, H. Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Care, and the Patient with a Life-Threatening Illness, 5th Ed • Quill, T, Arnold, R. Back, A. Discussing Treatment Preferences with Patients who want “everything”. Annals of Internal Medicine 2009; 151:345-349 • Volicer, L. Futility Discussion Revisited. JAMDA 2010; 11(6): 389-390 • Weissman, D. Decision Making at a time of Crisis Near the End of Life. Journal of America Medical Association 2004; 292(14):1738-1744 • http://www.cwag.org/legal/guardian%2Dsupport/ • http://www.dhs.wisconsin.gov/forms/AdvDirectives/ • http://evercarehealthplans.com/