Promise 5: We will appropriately follow plans
This promise involves a strong commitment to monitoring the effectiveness of advance care planning outcomes. After all, what good are the plans if there is little evidence they are being followed or have an impact on decision-making at the end-of-life? It includes selecting appropriate outcomes to measure, collecting data and making on-going improvements. This promise also means creating effective mechanisms that can respond to situations where it appears the plans are not being followed.
To assess if an organization or community is meeting this promise, the following questions could be asked:
- Are patient preferences as indicated in the advance directive reflected in the patient's medical record?
- Is there a mechanism to monitor the effectiveness of the written plan?
- Is there a system to respond to situations when it appears that the plan is not being followed?
- Are the patient's family and chosen surrogate satisfied that the plan is being carried out according to the patient's previously expressed wishes?
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This content is provided by Gundersen Lutheran Medical Foundation. Citation: Hammes, Bernard J., Briggs, Linda, "Respecting Choices Advance Care Planning Facilitators Manual," Gundersen Lutheran Programs for Improving
End-of-Life Care, Gundersen Lutheran Medical Foundation, 2000. http://www.gundluth.org/eolprograms