The Common Sense Guide to Improving Palliative Care > Advance Care Planning > 3.7 Identifying and Testing Changes

This extract from the online edition of The Common Sense Guide to Improving Palliative Care is used with permission.

Advance Care Planning: Identifying and Testing Changes

Team Delta

Once Team Delta finalized its aims and how to track them, it looked at best practices to identify good ideas to try on the study unit in order to improve advance care planning (ACP). The team decided to try the following ideas:

1. Invite residents and families to attend a class that provides information on various options and helps them to complete ACP forms.
2. Offer mandatory classes for clinicians to help them understand and initiate ACP discussions, including role playing.
3. Involve frontline staff, such as admissions clerks, to get the advance directive forms completed and entered into the system.
4. Develop a staff education and public awareness campaign within the facility to raise awareness, understanding, and recognition of the importance of ACP.
5. Make ACP review part of the routine quarterly interdisciplinary team (IDT) meetings.
6. Reach out to hospital partners to settle on standardized and adequate documentation and "transfer" procedures for ACP.

With the help and dedication of team members, Team Delta tried one change at a time. Once a strategy showed better results, they implemented it on a larger scale.

There are a number of ways that you can improve ACP for your patients. Here are some interventions that QI teams have tried and that have proven successful:

Change Ideas to Improve ACP

• Develop a systematic approach and designate providers to initiate, document, and complete ACPs (e.g., list of topics to cover, who is responsible for each item, where the documents will be kept, etc.).
• Add a pop-up box about ACP availability on the computer order screen (e.g., when DNR order is written, at admission, or at discharge from the hospital).
• Conduct automatic ACP review at quarterly IDT conferences in long-term care institutions.
• Incorporate questions about proxy and DNR orders into admission forms with more comprehensive follow-up by clinicians (e.g., ACP "SWAT" team) while in the hospital or nursing home.
• Encourage time-limited trials for invasive technology or treatments with agreement about when to stop.
• Be clear about DNR and proxy orders at admission; use community follow-up (with primary-care physicians, community social workers, home health providers, and other providers in the system) to continue and complete ACP documents and periodically review them with patient and family.
• Standardize ACP procedures, to be completed in a set time frame (e.g., 72 hours after admission; within one week of admission; etc.).
• Develop standardized "scripts" for starting ACP discussions. One of the best openings: "At this time in your life, what is it that makes you happy?" Then, ask the same question regarding what makes you "sad" or "anxious." Then discuss prognosis and other difficult issues (see Physician Orders for Life-Sustaining Treatment (POLST) in the Resources section at the end of this chapter).
• Implement a standardized healthcare proxy form for use throughout the institution.
• Train clinicians to conduct family meetings, help patients and families to express wishes and make decisions, and document the settled plan of care.
• Develop posters, brochures, and similar material for patients and family members. For example, staff can wear buttons that ask, "I Have an Advance Care Plan, Do You?" or "Ask Me about Advance Care Planning."
• Monitor the process of ACP and patient and family reaction to it, as well as the accuracy of documentation of patient wishes on transfer.
• Make plans about the patient's preferred place to die.

As you think about changes you would like to make, plan for obstacles. QI teams frequently encounter similar barriers, regardless of the setting in which they are working. Below is a list of common barriers; remember that others have overcome them—and you can, too:

Common Barriers to ACP

• Not being able to offer key treatment options, such as palliative sedation or clinician visits in the home for symptom exacerbation, really limits how much you can improve things for your patients.
• "The big lie" that all will be well and that we do not need to deal with this. For example, during inpatient rehabilitation for older people, it is tempting to communicate a sense that the patient is not really up against a serious, chronic condition but is just a little off course and on the verge of recovery. That lie means not only that death comes as a shock to family but also that no useful care planning can take place.
• Patients may express a desire to die at home, but the caregiver may fear being unable to manage worsening health at home. In this case, you need to think about what you can really offer in terms of support (on-call physicians, hospice, oxygen, etc.) and what the family can manage.
• Multiple physicians and other providers, with no real communication among them, leave the patient and family with the sense that no one is in charge or responsible, that no one grasps the situation accurately, and that no one can really ensure that the ACP is followed.
• Providers may be reluctant to "bring up bad news" (e.g., they may be uncomfortable with the conversation, they do not know how to start such a talk, etc.). In this case, groups find that providing physicians and nurses with a script to follow helps them overcome their anxieties.
• Providers fear that patients do not want to have these discussions.