The content and quality of advance care planning discussions should be individualized and based on a variety of factors: the needs of the individual, the situation, the immediacy of a decision, the skill of the Advance Care Planning Facilitator. Good advance care planning begins with an assessment of these factors and leads to appropriate referrals and effective follow-up plans. A health professional may feel confident and prepared to begin an advance care planning discussion, to provide information and explanations; yet not confident or prepared to facilitate a discussion with an individual who is weighing the benefits and burdens of cardiopulmonary resuscitation.
To assist with an assessment of the needs of the individual seeking advance care planning and to appropriately identify the requisite skills of the facilitator, the following categories have been designed. They provide a general outline of the types of questions and concerns each group might have and thus identify the related skills required of an advance care planning facilitator.
A. Affirm your relationship and assure the individual you care about them, will not abandon them and will assist them in developing a plan over time, when they're ready.
B. Inform the patient that these discussions are part of good care, that health professionals cannot respect a patient's choices if their values, goals, and choices are not known. The goals are to begin to explore the issues, answer questions and understand your preferences.
C. Provide support that making decisions about how to live well at the end of life does not mean there is nothing more that can be done. We always can and will do something to make the dying process as comfortable as possible and desired by the patient.
D. Schedule adequate time to begin these conversations. It may be useful before proceeding with specific discussions, to prepare the individual by providing them with written information or videos, blank advance care planning worksheets and asking them to decide who they would want included in these conversations.
2. Assess the motivation, knowledge and beliefs of the person seeking assistance. By allowing and encouraging the patient to tell their story of why they want or need to talk about end-of-life decisions and what experiences they've had, a more comfortable environment is created. Individuals will trust you are there to assist them to understand and reflect rather than press for immediate decisions. Ask the individual if they have thought about the type of care they would want if their health condition got worse and they could no longer speak for themselves.
3. Assess the individual's understanding of their health condition. It is difficult if not impossible for individuals to envision end-of-life issues if they do not understand the consequences of their current state of health.
4. Provide education and facilitate understanding of their medical condition. What are the barriers? What does this person need to adequately understand?
5. Explore and clarify patient statements and preferences. Vague statements such as "I don't want to be hooked to machines," or "I just want to be comfortable" need to be explored to avoid confusion should the patient become incapacitated.
6. Develop a plan of action to have further discussion and/or complete an advance directive. With early and thoughtful planning discussions, adequate time is available to ideally formulate a document that is meaningful and useful in respecting the individual's preferences. Consider the following actions:
A. Provide education on the advance directive document.
B. Assist the individual in choosing an appropriate surrogate by:
1. Providing information regarding state law and responsibilities of a surrogate decision-maker.
2. Providing criteria to consider in selecting the most appropriate surrogate:
- Is the person willing?
- Does the person understand the patient's preferences and goals?
- Can the person make decisions under pressure?
- Will the person honor or follow the plan?
3. Include the surrogate in discussions as soon as possible or encourage the patient to specifically discuss treatment preferences with them.
4. Provide the surrogate with information, support and guidance to understand their role and promote optimal communication among all parties.
C. Provide blank advance directive worksheets, requesting individuals and their surrogates begin to discuss and write down the patient's decisions.
D. Make referrals to other health professionals as needed to provide more information and counseling opportunities.
E. Schedule return visits to review information provided and written treatment decisions.
F. Document all discussions and plans of care. Provide a written summary of the conversations for the individual to take home.
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