II. Types: Concepts in Advance Care Planning
III. Protocol: Process for Advance Care Planning
- Document patient's values and cultural beliefs
- Determine health care preferences when patient healthy
- Patient selects Durable Power of Attorney
- Ongoing dialog with patient and their family
IV. Approach: Gradual introduction for patients regarding Advanced Directives
- Routine patient visits at ages 50 to 65 years old
- Provide Advance Directive forms
- Consider mailing prior to preventive health visits
- Consider including as link from online appointment scheduling
- Review forms and answer questions at each routine physical exam
- Consider referral to clinic nurse for discussion
- Consider group sessions for education about Advance Directives
- Dialogue example
- "How would you like to be cared for if you had a devastating injury or illness"
- Provide Advance Directive forms
- Diagnosis and maintenance of progressive chronic disease
- Discuss how health changes have impacted patient's Advance Directive goals
- Update forms to account for these changes
- Increased Frailty and dependency (e.g. Nursing Home Admission)
- Discuss prognosis and patient's Advance Directive goals
- Discuss Resuscitation and life support options
- Update forms
V. Resources
- Lynn: Improving care for the end of life
- National Hospice and Palliative Care Organization