Advance care planning discussions among residents of long term care and designated assisted living: experience from Calgary, Alberta

Abstract

ObjectivesPatients, physicians and the healthcare system are faced with the challenge of determining, and respecting, the medical wishes of an aging population. Our study sought to describe who participates in advance care planning (ACP) and decision-making for patients in long-term care and designated assisted living.MethodsIn 2008, Alberta Health Services initiated its ‘Advance Care Planning: Goals of Care Designation’ (Adult) policy in the Calgary zone. This policy encouraged discussions about goals of care and used a tracking form to capture these conversations. A postpolicy implementation chart review was performed at 3 time points: at baseline, at 6 months and at 18 months post implementation in long term care (LTC) and designated assisted living sites.Results166 charts were reviewed and 90% had a documented goals of care order. Less than half of residents (47%) were documented as participating in conversations and they were less likely to participate if they had cognitive impairment and were living in LTC. Documented family participation was more prevalent in LTC (51% vs 11%). Nurses participated in 67% of documented conversations with only 34% of discussions documenting physician involvement.ConclusionsThis study identifies the lack of documented resident participation in ACP in LTC. While this finding may be explained by the high prevalence of cognitive impairment in our population, it raises questions about the optimal approach to ACP in LTC. In this setting, ACP appears to be more about relational autonomy than it is about patient autonomy.

How healthcare systems evaluate their advance care planning initiatives: Results from a systematic review

“…However, many residents in continuing care already have impaired capacity for decision-making. 22 For ACP to realize its full potential, it needs to occur earlier in the illness trajectory, and healthcare systems thus need to focus on implementing ACP in other settings, before individuals enter continuing care.…”

“…However, many residents in continuing care already have impaired capacity for decision-making. 22 For ACP to realize its full potential, it needs to occur earlier in the illness trajectory, and healthcare systems thus need to focus on implementing ACP in other settings, before individuals enter continuing care. To begin to examine how well the current ACP evaluative strategies are covering important quality of care domains, we mapped the categories of indicators onto an IOM-Donabedian matrix (Table 4).…”

Advance Care Planning: Identifying System-Specific Barriers and Facilitators

“…Development of the survey instrument used published evidence on barriers and facilitators to uptake of acp 9 , the Theoretical Domains Framework 10,11 , and early experience from the implementation of acp/gcd in Calgary, Alberta 12 . The interview questions were designed to investigate specific barriers and facilitators to the implementation of acp/ gcd within Alberta, reflecting domains of the Theoretical Domains Framework (Table i).…”

Culturally Competent Palliative and Hospice Care Training for Ethnically Diverse Staff in Long-Term Care Facilities

“…Higher levels of family caregiver satisfaction was related to friendly and reliable staff, and low satisfaction was related with lack of time among the staff in providing care. [50][51][52] Staff and family conflict occurred when staff members felt they did not have enough time to complete the task. 48 Good communication between health professionals and with patients and families led to greater family satisfaction.…”

“…55 In a medical chart review study, nurses participated in 67% of documented conversations regarding ACP versus 34% of physician involvement. 51 Physician and family caregiver communication improved when physician met face-to-face with the family. 56 In a study by Guerriere et al, 57 reported family satisfaction of nursing home staff quality-of-life indicators were (1) always spent enough time, (2) never arrived late, (3) never been hard to reach, (4) never seemed distracted, (5) always been willing to take time to listen, (6) treated as a person, (7) always showed personal concern, and (8) always responded, never ignored.…”