Title : Advance care planning program
Abstract:
Advance Care Planning is defined as a process that supports adults at any age or stage of health in understanding and sharing their values, goals, and preferences regarding future medical care. The goal is to help ensure that people receive medical care that is consistent with their preferences during serious and chronic illness. Operationally, Advance Care Planning at the Cleveland Clinic is defined for all adults to have their surrogate decision maker, and for seriously ill patients to also have goals of care conversations documented in the electronic medical record. The Cleveland Clinic created a specific Advance Care Planning navigator as the single source of truth, which contains Advance Directive documents, or the contact information of the surrogate per state law hierarchy, as well as goals of care discussions as Advance Care Planning notes. Goals of care are voluntary discussions between the seriously ill patient or surrogate, and the clinical team. Goals of care discussions include exploring understanding of current condition, sharing prognosis, exploring what matters most to the patient, and developing a collaborative plan. Early goals of care discussions are associated with better quality of life, reduced use of life-sustaining treatments near death, earlier hospice referrals, and care that is consistent with patient preferences. At the Cleveland Clinic we trained different teams to have advance care planning conversations with patients, however we learnt that it is hard for clinical teams to incorporate these discussions in their busy day. An interdisciplinary team from Clinical Transformation designed an innovative proof-of-concept program implemented by Nurse Practitioners to proactively approach high-risk patients to have advance care planning conversations. This program was implemented in December 2022 at two regional hospitals. Nurse practitioners proactively approach patients admitted to the hospital in the medical service with high-readmission risk or high-prognostication risk scores, or patients older than 65 years old with previous code status orders in the electronic medical record. They also approach patients by primary teams’ referrals from geriatric-behavioral unit, surgery, or emergency department. They conduct and document advance care planning conversations, that includes surrogate decision maker documentation helping them to complete advance directives documents if patient desires; exploration of values, wishes and worries; encourage patients to have conversations with surrogates and doctors using “The Conversation Project” tools, and address code status. They also identify which patients would benefit from palliative care consults or hospice referrals using the Palliative Performance Scale and the Clinical Frailty scale.
Audience Take Away Notes:
- The definition of advance care planning and how patients benefit from it
- How to identify patients who benefit from advance care planning
- The results of a new advance care planning program
