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Educate Staff on Advance Care Planning to Meet Residents' Needs

Advance care planning (ACP) offers benefits by ensuring goals and preferences of long-term care residents are being met, emotional stress for surrogates is reduced and a basis for informed conversations and treatment decisions is available for providers.

Advance care planning prepares residents and their caregivers to make important decisions about treatment and end-of-life care. It is important to foster this autonomy in medical decision-making by helping individuals maintain control of how they live right up until the very end by focusing on treating the “whole person.” A holistic advance care plan provides residents and their surrogates with a sense of fulfillment knowing their preferences are known and will be respected.

Long-term care facilities can support residents and their surrogates by educating staff to assess and meet an individual resident’s needs according to the resident’s routine and preferences. In a recently reviewed congressional report, the U.S. Department of Health and Human Services (HHS) recommends that goals of care are informed by a patient’s present condition and decisions are prospectively mapped out so that comfort and resource use are maximized and anxiety is minimized.

For the full benefits of advanced care planning to be experienced by a resident, it’s imperative for providers at all levels, in all health care settings, to understand common pitfalls with implementing advanced care plans that often lead to adverse events or medical errors. The two most common pitfalls are attributed to failures in communication and documentation. The tables below highlight a few implementation pitfalls and best practices.


Implementation Pitfall Best Practice

Provider communication between shifts or settings

Ensure pre-existing ACP documentation is updated regularly, treatment options are prospectively mapped out and changes are captured in real time.

Health care providers lack knowledge and participation in the ACP process Develop a process for front-line staff to discuss palliative approaches and share resident preferences, for or against life-sustaining treatment, whether ACP was completed or not.

Surrogate decision-maker not available

Develop a clinical decision support tool for front-line staff to follow to aid in treatment decision making. 


Implementation Pitfall Best Practice

Frequent care plan updates

Invite external partners such as EMS, hospitals and other acute or chronic care services such as dialysis, to regular QAPI meetings to improve coordination of information.
Status changes: knowledge sharing and accessibility

Consider using analog methods to indicate a change has been made such as phone calls, text message alerts for surrogates, use of wristbands or other written records or visual cues. 

Mismatched electronic medical records (EMRs)  between providers

Complete health information exchange with local agencies and organizations (EMS, hospitals, clinics).

Lack of standard documentation in the EMR Document ACP discussions in a standard, easily accessible location in the EM.

The benefits of advance care planning can be experienced through successful program implementation that focuses on avoiding common pitfalls and are built upon a person’s goals of care both for their present condition and future preferences of treatment.

Check out the resources below for more best practices and stay tuned for our next installment to learn more about equitable and inclusive advanced care planning.

If you have a best practice to share, please email Adrienne Butterwick or Andy Romero.


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