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Advance Care Planning and End of Life Care

Advance Care Planning


Advance care planning is making decisions about the care you would want to receive if you become unable to speak for yourself. These are your decisions to make, regardless of what you choose for your care, and the decisions are based on your personal values, preferences, and discussions with your loved ones.

Advance Care Planning for Residents - Role and Responsibilities of Long-Term Care Ombudsmen

Planning in advance about care you would want to receive, or not, if you become unable to speak for yourself gives a person the ability to direct that their values and preferences are taken into account. Advance Care Planning often includes such things as:

  • Identifying a surrogate decision-maker
  • Discussing with loved ones individual choices and preferences in the event of a life-threatening illness or injury
  • Completing Advance Directive forms such as a Durable Power of Attorney or health care directive

This webinar discusses how long-term care ombudsmen can best support a resident who wants to do advance care planning, or for those residents whose wishes are not being respected by the facility, family, or friends, as well as what resources are available for information sharing and advocacy.  Speakers included Charles Sabatino, Director, American Bar Association Commission on Law and Aging; and Maria Greene, NORC Consultant.

 

Click here to view the full PowerPoint Presentation.

Physician Orders for Life-Sustaining Treatment (POLST)

The POLST system converts patient preferences for life-sustaining treatment into actionable medical orders by providing clear instructions as to what treatments the patient would like as it relates to the use of:

  • cardiopulmonary resuscitation,
  • antibiotics and IV fluids,
  • a ventilator to help with breathing, and
  • artificial nutrition by tube.

The POLST form, which is a brightly colored form outlining an individual’s wishes in these four areas, is designed to clear up many of the problems associated with Advance Directives, such as vague wording regarding what interventions a patient may want, a proxy decision maker who does not understand the patient’s wishes, and not having the Advance Directive form available to emergency personnel. POLST forms are intended to complement Advance Directives, not replace them.

POLST provides the individual with the opportunity to document his/her treatment goals and preferences, thus permitting increased individualization. The POLST form is signed by the patient and the physician and becomes a set of medical orders. The POLST form transfers across treatment settings, so it is available to an array of health care professionals (EMTs, nursing home staff, physician, hospitals).

POLST Resources:

POLST and other Advance Care Planning Tools (October 2013)
This session from the 37th annual Consumer Voice conference discusses Physician Orders for Life Sustaining Treatment (POLST) Programs cropping up all over the country. What are they? How do they work? POLST and other advance care planning tools are designed to promote individual decision-making and choice over care and treatments at the end of life. Read about how one state has been implementing and educating about POLST.

10 FAQs: Medicare's Role in End-of-Life Care (December 2015) 
Created by the Henry J. Kaiser Family Foundation. This FAQ sheet can help better understand the largest insurer of health care provided during the last year of life. This information will help explain the coverage that is offered, changes to be made in the future, and cost. In addition, these FAQs describe recent relevant rules released by the Administration and additional proposals from Congress regarding advance care planning and care for people with serious and terminal illness

Overview of POLST (February 2013)
This resources provides an overview of the history of POLST, the benefits of the POLST system, implementation of POLST programs in the states and other challenges associated with POLST programs. 

Improving Advance Illness Care: The Evolution of State POLST Programs (April 2011)
This report by by Charles Sabatino, American Bar Association Commission on Law and Aging and Naomi Karp, AARP Public Policy Institute, explores the experience of 12 states with POLST programs to identify factors that helped or hindered adoption and meaningful implementation of the protocol.

POLST - Programs in Your State
Click on your state to find educational materials, forms and brochures about the state's POLST program.

End of Life Care


End-of-life care (or EoLC) refers to health care, not only of patients in the final hours or days of their lives, but more broadly care of all those with a terminal illness or terminal disease that has become advance, progressive and incurable.

10 FAQs: Medicare's Role in End-of-Life Care (December 2015)

Created by the Henry J. Kaiser Family Foundation. This FAQ sheet can help better understand the largest insurer of health care provided during the last year of life. This information will help explain the coverage that is offered, changes to be made in the future, and cost. In addition, these FAQs describe recent relevant rules released by the Administration and additional proposals from Congress regarding advance care planning and care for people with serious and terminal illness. 

Additional Resources


State Health Care Power of Attorney Statutes

The Dying in America: Conversations About Care at the End of Life podcast series (March 2016)
In this series, sponsored by the National Academy of Medicine, hear about various aspects of end-of-life care from the perspective of experts in the field. Topics include palliative care, interdisciplinary teamwork, clinician-patient communication and advance care planning, and policies and payment systems for care near the end of life.

Information to Share with Consumers


10 FAQs: Medicare’s Role in End-of-Life Care

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