III. Protocol: Process for Advance Care Planning

  1. Document patient's values and cultural beliefs
  2. Determine health care preferences when patient healthy
  3. Patient selects Durable Power of Attorney
  4. Ongoing dialog with patient and their family

IV. Approach: Gradual introduction for patients regarding Advanced Directives

  1. Routine patient visits at ages 50 to 65 years old
    1. Provide Advance Directive forms
      1. Consider mailing prior to preventive health visits
      2. Consider including as link from online appointment scheduling
    2. Review forms and answer questions at each routine physical exam
      1. Consider referral to clinic nurse for discussion
      2. Consider group sessions for education about Advance Directives
    3. Dialogue example
      1. "How would you like to be cared for if you had a devastating injury or illness"
  2. Diagnosis and maintenance of progressive chronic disease
    1. Discuss how health changes have impacted patient's Advance Directive goals
    2. Update forms to account for these changes
  3. Increased frailty and dependency (e.g. Nursing Home admission)
    1. Discuss prognosis and patient's Advance Directive goals
    2. Discuss Resuscitation and life support options
    3. Update forms

V. Resources

  1. Lynn: Improving care for the end of life
    1. http://www.medicaring.org/educate/
  2. National Hospice and Palliative Care Organization
    1. http://www.partnershipforcaring.org

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Ontology: Advance Care Planning (C0600371)

Definition (MSH) Discussions with patients and/or their representatives about the goals and desired direction of the patient's care, particularly end-of-life care, in the event that the patient is or becomes incompetent to make decisions.
Concepts Health Care Activity (T058)
MSH D032722
French PAS (Planification Anticipée des Soins), Planification anticipée du projet thérapeutique, Planification anticipée des soins
Swedish Förhandsplanering av vård
Czech předběžné plánování péče
Finnish Hoitotahdosta keskusteleminen
Russian MEDITSINSKOI POMOSHCHI PLANIROVANIE INDIVIDUAL'NOE, МЕДИЦИНСКОЙ ПОМОЩИ ПЛАНИРОВАНИЕ ИНДИВИДУАЛЬНОЕ
English Advance Care Planning, advance care planning, advance health care planning, Advance Health Care Planning
Japanese アドバンスケア計画
Italian Pianificazione preliminare dell'assistenza sanitaria, Pianificazione preliminare dell'assistenza
Polish Planowanie opieki wyprzedzające
Norwegian Forhåndsplanlegging av pleie, Forhåndsplanlegging av terminal pleie, Forhandsplanlegging av pleie, Forhandsplanlegging av terminal pleie
German Advance Care Planning
Dutch Professionele-zorgplanning
Portuguese Planejamento Antecipado de Cuidados
Spanish Planificación Anticipada de Atención