Advance Care Planning
Promoting Inter-Professional
Practice
Presented March 24, 2007
Presented by:
Jane Keleher, MSc OT Candidate
Philip Santiago. MSc OT Candidate
Kara Braun, Masters of Theological
Studies Candidate
Nadia Alam, MD
Definition of ACP
process of recurring clinician-patient-family
communication that includes
decisions related to life-extending treatments
such as resuscitation and dialysis;
quality of life issues such as symptom control;
preferences for the setting of care such as
hospice;
spiritual and emotional issues as they help
define medical decisions, relieve suffering,
and provide meaning and dignity
Dr. J.S. Weiner
Early project development
Originally master’s research project with
Dr. Heather Lambert
Emphasis on advance directive forms –
legally used or not?
Literature search highlighted move from
advance directive forms to advance
care planning process
Development with Quipped
Concept became interprofessional
Process of communication rather than
the advance directive forms
Move away from legal issues
Move toward emotional and spiritual
issues
Addition of Kara and Nadia to team
Advisors
Christine Chapman, QUIPPED
Dr. Cori Schroder, Palliative Care
Dr. Margo Paterson, Chair OT
Research Questions:
Can students imagine ACP as an inter-professional
practice informed by a broad spectrum of beliefs and
values, individual and professional?
Can inter-professional education provide a means by
which students become more comfortable with
ACP? Does this make the process of ACP easier?
Can ACP become a shared responsibility through
which health care professionals are better able to
appreciate the benefits of inter-professional practice?
Facilitators objectives
build a comfortable level of competency
in our own understanding of ACP
build a comfortable level of competency
in providing education to colleagues
Module objectives for
participants to demonstrate
Increased awareness of the importance of ACP and
what it entails
New or expanded knowledge of the
roles/responsibilities of various health care
professionals in ACP, emphasizing communication
Increased awareness of how personal belief systems
can affect the process of ACP
Appreciation of the importance of understanding and
respecting the values and beliefs of patients.
The Workshop
March 24, 2007
8:30 am - 12:30 pm
To start things off…
Expectations for the day.
Barry Smith’s video legacy.
David Rieff’s article about his mom,
Susan Sontag.
Brainstorming what ACP encompasses.
What is ACP?
ACP is a process of recurring clinician-patient
family communication that includes
decisions related to life-extending treatments
such as resuscitation and dialysis;
quality of life issues such as symptom control;
preferences for the setting of care such as
hospice;
spiritual and emotional issues as they help
define medical decisions, relieve suffering,
and provide meaning and dignity
Dr. J.S. Weiner
Historical perspective on ACP to current
endeavours.
The challenges of ACP… including a
little vignette: “The Untrained Clinician”.
“The Untrained Clinician”
Mr. C is a 73-year-old man with acute leukemia. During a hospitalization for
pneumonia, his physician, Dr. S, wishes to broach the subject of advance
directives.
Dr. S: How are you doing today?
Mr. C: OK, my breathing is a little better. But can you give me something to
sleep?
Dr. S: Sure, no problem. Anything else bothering you?
Mr. C: No, that's it.
Dr. S: Okay, well, I wanted to talk to you today about something called advance
directives. Do you know what that is?
Mr. C: I think so. I'm not sure.
Dr. S: Well, it's like decisions you need to make for the future. Medical
decisions. To tell us what you want us to do.
Mr. C: I'm not sure what you mean.
Dr. S: Well, if something happens we need to know what you want us to do
medically.
Mr. C: Like what?
Dr. S: Like if your heart stops beating or you stop breathing, do you want us to
put the tube in.
Mr. C: (confused silence).
Experiential Exercises
Self-reflection through visualization: The
Trunk in the Attic.
The case of a 19 y.o. boy, recent high school
grad, involved in a car crash while driving
under the influence of alcohol.
– Aspects of the case touched on dealing with
distraught family, spiritual angst, the possibility of
disability, and the potential for financial strain.
The Quality Quantity Questionnaire
Rietjens et al.
In order to live a bit longer, I would clutch at any straw.
If I would become seriously ill, I would accept every treatment that can prolong my
life, whatever the side effects may be.
If I would become seriously ill, I would always accept a hard-to-tolerate treatment,
even if the chance of its prolonging my life was as little as 1%.
If I would become seriously ill, I would probably manage to find the strength to
continue.
A moment might come in which I would say: “I have done my best, this is the limit.”
If a life-prolonging treatment would prevent me from leading a normal life, then I
would rather not have it.
I can imagine some side effects being so bad that I would refuse the treatment, even
if that meant a shorter life.
If I had to endure 6 months of hard-to-tolerate treatment in order to live for an extra
half year, then I would not be willing to get that treatment.
A Workshop to Teach Medical Students Communication
Skills and Clinical Knowledge About End-of-Life Care
Torke et al.
Opening the end-of-life/ AD discussion
–
–
–
–
–
Ask permission to talk.
Ascertain the patient’s understanding of the disease.
Ask about the patient’s emotional state.
Introduce the topic.
May need to reassure patient that you are not raising these
issues because he/she is about to die.
Assess pt preferences re: end-of-life care
– Explain treatment options at the end of life.
– Gain a deep understanding of patient preferences.
Torke et al. continued.
Critical steps to creating an AD
–
–
–
–
–
Identify pt preferences
Identify surrogate decision maker(s)
Plan to communicate with SDM re: preferences
Plan to communicate with health care providers re: preferences
Document preferences and SDMs
Supportive Closing
– Emphasis on active and engaged supportive care of the pt
– Arrange follow-up.
Living Well Interview Questions
Schwartz et al.
Maintaining or fulfilling what activities/ experiences are most important for you to feel
your life has qulaity or for you to live well? (What makes you happy?)
What fears or worries do you have about your illness or medical care?
If you have to choose between living longer and quality of life, how would you
approach this balance?
Are there any special events/ activities that you are looking forward to?
What needs or services would you like to discuss?
Do you want information about anything related to your present or future care?
What sustains you when you face serious challenges in life?
Do you have any religious or spiritual beliefs that are important to you?
In what way do you feel you could make this time especially meaningful to you?
What do you hope most for those closest to you?
Fitchett’s model of spiritual
assessment
1. Beliefs & meanings: higher purpose, meaning of life.
2. Authority & guidance: Individual/ group/ resource whom they
trust.
3. Experience & emotion: perception of events and
circumstances.
4. Fellowship: formal/informal community.
5. Ritual & practice: significance in activities, traditions.
6. Courage & growth: dealing with doubt, change and
challenges.
7. Vocation & consequences: their calling.
Emotional and Cognitive
Barriers
Weiner suggested that discussions
around ACP often raise strong emtions
(anxiety, frustration, anger, sadness,
hopelessness).
If these emotions are not properly dealt
with, they can become foci for
subsequent negative behaviour.
Reframing Barriers to ACP
Cognition: People generally do not want to
discuss issues related to death and dying.
Consequence: Displacing anxiety onto the
other (patient, family, your loved one),
depriving them of an important opportunity to
have input into their care.
Reframing Task: Shift this generalization to
consideration of what the particular patient
needs:
– What are your thoughts about your illness?
– What is the hardest part for you?
Reframing Barriers to ACP
Cognition: I will take away hope if I bring
up ACP
Consequence: This narrowly defines
hope as ‘hope to not die,’ which then
makes us feel hopeless and helpless.
Reframing Task: Redefine other kinds
of hope we can offer.
Reframing Barriers to ACP
Cognition: If I cannot offer cure I have failed; if my
services are not needed there is nothing for me to do.
Consequence: Possible to experience humiliation,
shame or helplessness.
Reframing Task: Consider the differences between
curing disease and healing suffering.
– Examine your openness to assume roles other than curing
disease.
Appreciating Our Unique
Functions in ACP
Mentor input: selected readings,
personal experience/expertise.
Sharing circle: participant input and
experience.
Results of the Workshop
Evaluation
Post-Module Questionnaire
– 9 Likert scale questions
– 6 open-ended questions
N = 20
– 2 Physiotherapy, 2 Theology, 2 Medicine, 6
Nursing, 8 Occupational Therapy
Quantitative Results
ACP: What it entails
– Increased general understanding of ACP
• 100% agreed or strongly agreed
– Increased appreciation of the importance
of ACP
• 100% agreed or strongly agreed
Quantitative Results
Inter-professionalism in ACP
– Increased understanding of one’s own
professional role/responsibility in ACP
• 65% agreed or strongly agreed
• 20% undecided
• 15% disagreed or strongly disagreed
Quantitative Results
Inter-professionalism in ACP
– Increased understanding of the
roles/responsibilities of other professionals
in ACP
• 85% agreed or strongly agreed
• 10% undecided
• 5% strongly disagreed
Quantitative Results
Role of personal belief systems in ACP
– Increased awareness of how one’s own values and beliefs
influence ACP
• 95% agreed or strongly agreed
• 5% unresponsive
– Increased awareness of the importance of understanding
and respecting the patient’s values and beliefs in ACP
• 100% agreed or strongly agreed
Qualitative Results
If you were to discuss ACP with a
patient or a loved one, what would be
some of the key components you would
consider?
– 3 main themes:
• Empowering the patient (70%)
• What ACP entails (65%)
• Personal belief systems (55%)
Qualitative Results
What do you perceive to be the benefits
to an inter-professional approach to
ACP?
– 5 main themes:
•
•
•
•
•
Synergistic team effort in ACP (50%)
Specialist role in ACP (40%)
Generalist role in ACP (10%)
Coordinated communication (5%)
Acknowledgment of patient affect (5%)
Qualitative Results
What do you perceive to be the
challenges to an inter-professional
approach to ACP?
– 4 main themes:
•
•
•
•
Coordinated communication (40%)
Time constraints (30%)
Specialist role in ACP (15%)
Lack of professional curriculum (10%)
Qualitative Results
What was the highlight of the module?
– 2 main themes:
• Workshop design (90%)
• What ACP entails (20%)
Qualitative Results
What did you enjoy least about the
module?
– 2 main themes:
• Too short (50%)
• Workshop design (30%)
Significance of the study:
explores an area of practice not well documented in
the literature on interprofessional education.
lack of educational initiatives on advance care
planning
valuable in the training of students and practitioners
alike.
invites exploration of future healthcare team
members’ values and beliefs
promotes awareness of the client’s vantage in ACP
Future applications
Deliver module as part of curriculum for
healthcare and theology students
Deliver module to interprofessional teams in
hospitals and long term care facilities
Adapt module for general public
– Know end of life care wishes earlier
– Normalize conversation around death and dying