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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 (NORC Webinar)
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. This webinar discusses how the Ombudsman program 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.  View the full PowerPoint Presentation.

National POLST Paradigm

The POLST program is a voluntary process supporting shared decision making between seriously ill or frail patients and health care providers.  The POLST form is a portable medical order that supports patients transitioning between health care facilities or living in the community by communicating their treatment preferences. In the event of a medical emergency, the POLST form tells emergency personnel what treatments to provide. 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:

National POLST Paradigm – Learn more information about the National POLST Paradigm.

Improving Advance Illness Care: The Evolution of State POLST Programs (April 2011)
This report 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.


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 (September 2016)
Created by the Henry J. Kaiser Family Foundation, these FAQs explain Medicare coverage for end-of-life care, changes to be made in the future, and cost.


Information to Share with Consumers

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

My Personal Directions for Quality Living Forms
This form can be used by consumers to record their personal preferences and information about themselves in case they need long-term care services in their home or in a long-term care community in the future. The information in this form may provide some help in understanding residents and help when providing their care. 



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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.

Overview of POLST (February 2013)
This resource 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.

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