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Advance Care Planning… is there a future?
Sandy Schellinger, RN MSN NP-C
LifeCourse Co-Principle Investigator
Allina Center for Healthcare Research & Innovation
Respecting Choices First and Next Steps National Faculty
Honoring Choices Minnesota
July 19, 2012
Causes of Death in Minnesota (117 people per day)
“Unexpected” Deaths
2
Heart Disease23%
Cancer24%
Lung Disease9%
Stroke6%
Diabetes3%
Other20%
Trauma 10%
Sudden Death
3%
Acute Stroke
2%
Causes of Death in Minnesota“Expected Deaths”
100 people every day
3
Heart Disease23%
Cancer24%Lung Disease
9%
Stroke6%
Diabetes3%
Other20%
The Future of ACP Depends on How we Address some Key Questions:
• Will we adopt a common definition of ACP?• How will ACP be delivered in a consistent and
reliable way to every person in need?• How will a written plan be created that is person-
centered and individualized?• What is the role of leaders in creating and
sustaining an ACP initiative?• How will research assist with dissemination of
ACP?
Defining ACP: Current World
• ACP is interchanged with Advance Directives (Ads)
• Focus is still on completing Ads despite evidence of their ineffectiveness
• Selected proxies are unprepared
• Written plans are vague or ambiguous; don’t guide clinical decision making
ACP IS UNIVERSALLY DEFINED
Future World….
End of Life Care Dilemma
Goals Definition
Comfort Care
Comfort and relief of pain/symptoms Quality of life > length of life; Avoid
calling 911, ER or No more hospitals Hospice Care.
POL
ST
Limited Intervention
Treat reversible conditions not cure Limit high burden treatments; Live longer to achieve specific goals or
states of condition
CO
MPL
EX
/D
ISE
ASE
SP
EC
IFIC
A
CP
Aggressive Care
To Cure and reverse condition; Length of life > quality of life; Willing to risk suffering to live longer
BA
SIC
AC
P
diagnosis TIME death
Low
Burd
en o
f illn
ess
H
igh
adap
tatio
n
Advance Care Planning…
• Is Not A “One Size Fits All” Discussion
• Must Be Individualized To Patient Readiness And Stage Of Health
diagnosis TIME death
Low
Burd
en o
f illn
ess
H
igh
adap
tatio
n
The Life Course of Advance Care Planning
Basic ACP group sessions•Basic HCD completion•ID Health care agent•Clarify goals values •Treatment wishes in the face of neurological injury
DSACP sessionFacilitator, patient, proxyIndividualized HCD 90 minute sessionDiscuss goals of care &complication results in “bad” outcome.
POLST:Provider Orders for Life Sustaining TreatmentHospice/LTC patientsMedical order set with specific goals and wishes
Time
Func
tion
Healthy adults age 65
Adults any age with progressive advanced illness complications
Adults any age who you would not be
surprised they died in the next 6-12 months.
Advance Care Planning
• Is a process of communication
• Separate and distinct activity from the creation of a written plan (e.g., advance directive)
• Is a service offered to individuals by qualified individuals
The Goals of Advance Care Planning
• To assist individuals to take control of their future healthcare decisions
• To make informed decisions based on their current stage of health, goals, values (religious and cultural) and beliefs
• To prepare substitute decision makers for a future decision making role
• To communicate this plan to those who need to know
• To provide care consistent with the plan
THE DELIVERY OF A CONSISTENT AND RELIABLE ACP SERVICE
The Future World
The Components of an ACP Service
• ACP conversations are standard routine care
• ACP is initiated by healthcare providers and others at appropriately staged
• ACP is individualized (person-centered)
• ACP is delivered by trained individuals
• ACP is delivered by a team people with varying roles and responsibilities.
The Role of the ACP Facilitator: Current
• Disagreement on who should be doing ACP
• Lack of understanding on what the facilitation service should be
• Lack of standards in delivering a consistent and reliable standard
• Lack of time and reimbursement
• Lack of standardized training
The Emerging Role of the ACP Facilitator
• A new healthcare role
• Standardized training and certification
• Roles and responsibilities defined
• A care coordinator type of role
• Part of a team
• Reimbursed for services
The Advance Directive Document: Current World
• Focus on a legal form• Rigid reliance on
contents of written document
• Restrictive language
• Format does not promote dialogue
• Promotes false sense of security
• May be a barrier for discussion
• Evidence shows not effective
PLANS WILL BE FLEXIBLEThe Future World
AD Document: Future World
• Creation of less restrictive forms
• Plans will become more specific as people get sicker
• Plans will be accessible
LEADERSHIP WILL SUSTAIN ACP INITIATIVES
The Future World
Leadership Matters: Future World
• Leaders integrate ACP into the strategic mission
• “it may not be a good business model, but it’s the right thing to do”…CME/CEO
• Dedicate resources to sustain an ACP program
• Committed ongoing quality
improvement
Local Initiatives
• RARE ---
– Readmission reduction
• ACO ---
– Pioneer Accountable Care Organizations
• Medical Home
• Care Choice
– PIP Grant
25
Kaiser Permanente of Northern California
“Our goal is for Life Care planning to become a routine part of care within Kaiser Permanente Northern California, for all our adult members across the continuum of care”
C-TAC: Coalition to Transform Advanced Carehttp://advancedcarecoalition.org/
30
Agency for Integrated Care: Singapore
Advance Care Planning and End of Life Carehttp://acpelsociety.com/index.php
32
Alberta
Ontario
B.C.
Future World…Will you be the change to sustain a World-Wide Imperative?
