Advance Care Planning…
is there a future?
Sandy Schellinger, RN MSN NP-C
LifeCourse Co-Principle Investigator
Allina Center for Healthcare Research & Innovation
Respecting Choices First and Next Steps National Faculty
Honoring Choices Minnesota
July 19, 2012
Causes of Death in Minnesota
(117 people per day)
“Unexpected” Deaths
Trauma 10%
Other
20%
Diabetes
3%
Acute Stroke
Stroke 2% 6%
2
Heart Disease
23%
Sudden
Death
3%
Lung Disease
9%
Cancer
24%
Causes of Death in Minnesota
“Expected Deaths”
100 people every day
Heart Disease
23%
Other
20%
Diabetes
3%
3
Stroke
6% Lung Disease
9%
Cancer
24%
The Future of ACP Depends on How
we Address some Key Questions:
• Will we adopt a common definition of ACP?
• How will ACP be delivered in a consistent and
reliable way to every person in need?
• How will a written plan be created that is personcentered and individualized?
• What is the role of leaders in creating and
sustaining an ACP initiative?
• How will research assist with dissemination of
ACP?
Defining ACP: Current World
• ACP is interchanged
with Advance
Directives (Ads)
• Focus is still on
completing Ads
despite evidence of
their ineffectiveness
• Selected proxies are
unprepared
• Written plans are
vague or ambiguous;
don’t guide clinical
decision making
Future World….
ACP IS UNIVERSALLY
DEFINED
 Comfort and relief of pain/symptoms
 Quality of life > length of life; Avoid
calling 911, ER or No more hospitals
 Hospice Care.
Limited  Treat reversible conditions not cure
Intervention  Limit high burden treatments;
 Live longer to achieve specific goals or
states of condition
Aggressive  To Cure and reverse condition;
Care
 Length of life > quality of life;
 Willing to risk suffering to live longer
COMPLEX/
DISEASE
SPECIFIC
ACP
Comfort
Care
POLST
Definition
BASIC ACP
Goals
End of Life Care Dilemma
diagnosis
TIME
death
Low
adaptation
Burden of illness
High
Advance Care Planning…
• Is Not A “One Size Fits All” Discussion
• Must Be Individualized To Patient
Readiness And Stage Of Health
diagnosis
TIME
death
Low
adaptation
Burden of illness
High
Function
The Life Course of Advance Care Planning
Basic ACP group sessions
•Basic HCD completion
•ID Health care agent
•Clarify goals values
•Treatment wishes in
the face of neurological
injury
Healthy adults age 65
DSACP session
Facilitator, patient, proxy
Individualized HCD
90 minute session
Discuss goals of care &
complication results in
“bad” outcome.
Adults any age with
progressive advanced
illness complications
Time
POLST:
Provider Orders for
Life Sustaining
Treatment
Hospice/LTC patients
Medical order set
with specific
goals and wishes
Adults any age who you
would not be surprised
they died in the next
6-12 months.
Advance Care Planning
• Is a process of communication
• Separate and distinct activity from the
creation of a written plan (e.g., advance
directive)
• Is a service offered to individuals by
qualified individuals
The Goals of Advance Care
Planning
• To assist individuals to take control of their
future healthcare decisions
• To make informed decisions based on their
current stage of health, goals, values (religious
and cultural) and beliefs
• To prepare substitute decision makers for a
future decision making role
• To communicate this plan to those who need to
know
• To provide care consistent with the plan
The Future World
THE DELIVERY OF A CONSISTENT
AND RELIABLE ACP SERVICE
The Components of an ACP
Service
• ACP conversations are standard routine
care
• ACP is initiated by healthcare providers
and others at appropriately staged
• ACP is individualized (person-centered)
• ACP is delivered by trained individuals
• ACP is delivered by a team people with
varying roles and responsibilities.
The Role of the ACP Facilitator:
Current
• Disagreement on who • Lack of standards in
should be doing ACP
delivering a
consistent and
• Lack of understanding
reliable standard
on what the
facilitation service
• Lack of time and
should be
reimbursement
• Lack of standardized
training
The Emerging Role of the ACP
Facilitator
•
•
•
•
•
•
A new healthcare role
Standardized training and certification
Roles and responsibilities defined
A care coordinator type of role
Part of a team
Reimbursed for services
The Advance Directive
Document: Current World
• Focus on a legal form
• Rigid reliance on
contents of written
document
• Restrictive language
• Format does not
promote dialogue
• Promotes false sense
of security
• May be a barrier for
discussion
• Evidence shows not
effective
The Future World
PLANS WILL BE FLEXIBLE
AD Document: Future World
• Creation of less restrictive forms
• Plans will become more specific as
people get sicker
• Plans will be accessible
The Future World
LEADERSHIP WILL SUSTAIN
ACP INITIATIVES
Leadership Matters: Future World
• Leaders integrate ACP into the strategic
mission
• “it may not be a good business model, but
it’s the right thing to do”…CME/CEO
• Dedicate resources to sustain an ACP
program
• Committed ongoing quality
improvement
Local Initiatives
• RARE --– Readmission reduction
• ACO --– Pioneer Accountable Care Organizations
• Medical Home
• Care Choice
– PIP Grant
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Allina LifeCourse
http://www.tpt.org/lifecourse/
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Kaiser Permanente of
Northern California
“Our goal is for Life Care planning to
become a routine part of care within
Kaiser Permanente Northern California,
for all our adult members across the
continuum of care”
C-TAC: Coalition to Transform Advanced Care
http://advancedcarecoalition.org/
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Agency for Integrated Care:
Singapore
Advance Care Planning and End of Life Care
http://acpelsociety.com/index.php
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Ontario
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Future World…
Will you be the change to sustain a World-Wide Imperative?
Questions?
sandra.schellinger@allina.com
612-262-1444