Improving advance care planning: lessons from POLST. Physician Orders for Life-Sustaining Treatment

Advance care planning for residents in aged care facilities: what is best practice and how can evidence-based guidelines be implemented?

Background  Advance care planning in a residential care setting aims to assist residents to make decisions about future healthcare and to improve end-of-life care through medical and care staff knowing and respecting the wishes of the resident. The process enables individuals and others who are important to them, to reflect on what is important to the resident including their beliefs/values and preferences about care when they are dying. This paper describes a project conducted as part of the Joanna Briggs Institute Clinical Aged Care Fellowship Program implemented at the Manningham Centre in metropolitan Melbourne in a unit providing services for 46 low and high care residents. Objectives  The objectives of the study were to document implementation of best practice in advance care planning in a residential aged care facility using a cycle of audit, feedback and re-audit cycle audit with a clinical audit software program, the Practical Application of Clinical Evidence System. The evidence-based guidelines found in 'Guidelines for a Palliative Approach in Residential Aged Care' were used to inform the process of clinical practice review and to develop a program to implement advance care planning. Results  The pre-implementation audit results showed that advance care planning practice was not based on high level evidence as initial compliance with five audit criteria was 0%. The barriers to implementation that became apparent during the feedback stage included the challenge of creating a culture where advance care planning policy, protocols and guidelines could be implemented, and advance care planning discussions held, by adequately prepared health professionals and carers. Opportunities were made to equip the resident to discuss their wishes with family, friends and healthcare staff. Some residents made the decision to take steps to formally document those wishes and/or appoint a Medical Enduring Power of Attorney to act on behalf of the resident when they are unable to communicate wishes. The post-implementation audit showed a clear improvement as compliance ranged from 15-100% for the five audit criteria. Strong leadership by the project team was effective in engaging staff in this quality improvement program. Conclusion  The outcomes of the project were extremely positive and demonstrate a genuine improvement in practice. All audit criteria indicate that the Manningham Centre is now positively working towards improved practice based on the best available evidence. It is hoped that as the expertise developed during this project is shared, other areas of gerontological practice will be similarly improved and more facilities caring for the older person will embrace evidence-based practice.

Strategies and innovative models for delivering palliative care in nursing homes

The goals of palliative care address critical issues for individuals with complex and serious illness residing in nursing homes, including pain and symptom management, communication, preparation for death, decisions about treatment preferences, and caregiver support. Because of the uncertain prognosis associated with chronic nonmalignant diseases such as dementia, many nursing home residents are either not referred to hospice or have very short or very long hospice stays. The integration of palliative care into nursing homes offers a potential solution to the challenges relating to hospice eligibility, staffing, training, and obtaining adequate reimbursement for care that aligns with resident and surrogate's preferences and needs. However, the delivery of palliative care in nursing homes is hindered by both regulatory and staffing barriers and, as a result, is rare. In this article, we draw on interviews with nursing home executives, practitioners, and researchers to describe the barriers to nursing home palliative care. We then describe 3 existing and successful models for providing nonhospice palliative care to nursing home residents and discuss their ongoing strengths and challenges. We conclude with specific policy proposals to expedite the integration of palliative care into the nursing home setting.

Health care professionals' perceptions and use of the medical orders for scope of treatment (MOST) form in North Carolina nursing homes

OBJECTIVES

To characterize the self-reported practices and opinions of nursing home (NH) health care professionals using the North Carolina Medical Orders for Scope of Treatment (MOST) form, an adaptation of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm.

DESIGN

A cross-sectional survey and semistructured interviews.

PARTICIPANTS AND SETTING

Six physicians, 3 nurse practitioners, and 2 social workers from 2 NHs in North Carolina.

MEASUREMENTS

Survey items covered timing and appropriateness of form completion, review criteria, barriers, and concerns about using the form. Interviews clarified survey responses and elicited descriptions of how subjects explain the scope of medical interventions to patients/families.

RESULTS

NH admission and routine care plan meetings were considered the most important times to complete the MOST form. Treatment options on the form were often introduced in the context of patient preferences for hospitalization; however, there were considerable differences in how health care professionals explained and interpreted the scope of medical interventions. Nearly all health care professionals (10/11) believed that the form improves communication between physicians and patients/families. Only 3 of 11 respondents were aware of all of the MOST form's review requirements. Time was the most commonly cited barrier to use of the form. Respondents were concerned about forms getting lost or not being honored outside of the NH.

CONCLUSION

Health care professionals generally viewed the MOST form as a useful tool for communicating patient treatment preferences in the NH. However, they may need specific strategies for explaining and interpreting the scope of medical interventions section and for meeting the form's review requirements.

Advance directives

Most patients want some control over their medical care, including-or even especially-when they are too sick to participate in decisions. Clinicians who have to make decisions for patients who are unable to participate often would appreciate guidance from patients' wishes. Advance care planning responds to these needs. The process provides for discussions about goals in different scenarios and allows inclusion of the family and physician as well as the patient. It helps to have the patient and family complete validated worksheets that walk them through the various considerations and result in expressions of preference that are clinically meaningful. For the clinician, scenario-based goals for care and personal thresholds for when desired care shifts from primarily cure-oriented to primarily palliative are the most useful features to know about. The patient and family should do most of the discussing on their own time; the physician and team should coordinate to screen for problems and ensure agreement. Ideally, this should occur over the course of regular clinical encounters, with some dedicated time for the topic at suitable intervals.