Digital Repository Doctoral Projects Fall 2022 Improving Advance Directive Education for Assisted Living Patients and Their Families D. Elise Butterfield Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Butterfield, D. E. (2022). Improving advance directive education for assisted living patients and their families Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. IMPROVING ADVANCE DIRECTIVE EDUCATION Improving Advance Directive Education for Assisted Living Patients and Their Families by D. Elise Butterfield A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah October 3, 2022 _______________________________ ______________________________ D. Elise Butterfield, DNP-FNP, RN Date _______________________________ _____________________________ Kristy A. Baron, PhD, RN Date Faculty Lead _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: The program director must submit this form and paper. Kristy A. Baron December 16, 2022 December 16, 2022 December 16, 2022 IMPROVING ADVANCE DIRECTIVE EDUCATION 1 Table of Contents Abstract ............................................................................................................................... 3 Improving Advance Directive Education for Assisted Living Patients and Their Families4 Background and Problem Statement ............................................................................... 4 Diversity of Population and Project Site ......................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership ................................. 6 Literature Review and Framework ..................................................................................... 6 Search Methods ............................................................................................................... 7 Advance Care Planning................................................................................................... 7 Impact of Advance Care Planning .............................................................................. 9 Barriers to Advance Care Planning........................................................................... 10 Advance Care Planning Conversations ......................................................................... 11 Patient and Family Education on Advance Care Planning ........................................... 13 Framework .................................................................................................................... 15 Discussion ..................................................................................................................... 15 Implications for Practice ............................................................................................... 16 Project Plan ....................................................................................................................... 16 Project Design ............................................................................................................... 17 Needs Assessment of Project Site and Population ........................................................ 17 Cost Analysis and Sustainability of Project .................................................................. 17 Project Outcomes .......................................................................................................... 18 Consent Procedures and Ethical Considerations........................................................... 18 Instruments to Measure Intervention Effectiveness ...................................................... 19 Project Implementation ..................................................................................................... 19 Project Intervention ....................................................................................................... 19 Project Timeline ............................................................................................................ 20 Project Evaluation ............................................................................................................. 21 Data Maintenance/Security ........................................................................................... 21 Data Collection and Analysis........................................................................................ 21 Findings......................................................................................................................... 22 Strengths ................................................................................................................... 22 Weaknesses ............................................................................................................... 22 Quality Improvement Discussion ..................................................................................... 23 Translation of Evidence into Practice ........................................................................... 23 Implications for Practice and Future Scholarship ......................................................... 23 IMPROVING ADVANCE DIRECTIVE EDUCATION 2 Sustainability............................................................................................................. 24 Dissemination ........................................................................................................... 24 Conclusion ........................................................................................................................ 24 References ......................................................................................................................... 26 IMPROVING ADVANCE DIRECTIVE EDUCATION 3 Abstract While the United States government has made strides in promoting advance care planning since the 1990s, there remains a general lack of paperwork completion overall. The COVID-19 pandemic has emphasized making these life-altering decisions before emergency hospitalization. People who have established their preferences for end-of-life care report a higher quality of life and autonomy with a decreased use of emergency care toward the end of life. Purpose: This DNP project highlights the role education has on an individual's likelihood of completing an advance directive in an assisted living setting. Methodology: This project provided a single teaching session to residents and family members of the Sarah Daft Home Assisted Living facility. A podcast from the Utah Coalition on Aging served as the primary education tool, followed by a discussion of the Utah Advanced Health Care Directive. Participants completed pre-and post-surveys designed to evaluate their knowledge and attitudes about advance care directives. Results: After the educational session, participants reported an increased knowledge level of advance directives, the likelihood of completing an advance directive, confidence that their loved ones would follow their wishes, and capability of how to update an advance directive. Additionally, post-teaching surveys indicated that 100% of participants supported advance directives. Implications for Practice: Providers who interact with patients across the lifespan should discuss advance directives with their patients. Provider-led advance directive education leads to informed decision-making and patient-centered care. Keywords: advance directive, end-of-life, autonomy, living will IMPROVING ADVANCE DIRECTIVE EDUCATION 4 Improving Advance Directive Education for Assisted Living Patients and Their Families As the baby boomer population ages, end-of-life planning conversations become critical. In 2030, all baby boomers will reach retirement age and account for nearly 20% of the population (United States Census Bureau, 2018). Additionally, more than four million Americans over 80 years of age will have dementia without a primary caregiver to address their needs (Miller, 2017). As of 2012, the number of people in Utah over 70 was 170,000 (Substance Abuse and Mental Health Services Administration, 2012). With a national average life expectancy of 78 years, older adults need to identify their wishes in writing for end-of-life care and designate a surrogate decision-maker. When adults identify personal preferences for end-of-life care, it promotes patient autonomy, improves quality of life, and prevents misunderstandings (National Institute on Aging, 2018). The Sara Daft Home is an assisted living facility that currently does not review or store advanced directive paperwork for its residents. Additionally, staff members are not trained to have meaningful conversations with patients regarding their advanced care wishes. This issue can lead to decreased quality of life, diminished family coping, and increased burden of care on community resources or loved ones. By incorporating a comprehensive advance directive education program for the Sarah Daft Home patients, they will have more opportunities for critical conversations with their families about their end-of-life wishes. This DNP project aims to increase the number of patients with advanced care planning (ACP) paperwork in an assisted living population. Background and Problem Statement The way death is discussed and how death occurs should incorporate patient-centered care, meaning the patient's preferences drive healthcare decisions. Providers are responsible for IMPROVING ADVANCE DIRECTIVE EDUCATION 5 facilitating meaningful end-of-life conversations with patients and families to help them make informed decisions (Halinski, 2020; Neumann, 2016; Periyakoil et al., 2015). Neumann further suggests that the idea of what constitutes a "good death" should be explored for every patient. Conversely, providers often delay "what matters most" conversations even when a poor prognosis is evident (Buss et al., 2017). Meaningful conversations facilitate a greater understanding of patient wishes and goals of care (Miller, 2017). Improved quality of life, increased patient autonomy, and reduced burdensome care are significant benefits of ACP. A randomized control trial by Detering et al. (2010) showed that cognizant hospitalized patients 80 years old and above (n = 309), who received ACP, were more likely to have a high-quality end-of-life experience than those without ACP interventions. Similarly, patients who outline their end-of-life care wishes more often opt out of intensive care treatment, hospitalizations, extreme lifesaving measures and are more likely to choose comfort-oriented care (Lum & Sudore, 2016; Andreassen et al., 2017). Furthermore, Lum and Sudore (2016) found that while fear of losing autonomy and dignity were common concerns for patients in their final days, those who participated in ACP reported a higher sense of personal fulfillment and control in their life. The benefits of ACP extend to family members as well. Detering et al. (2010) found that surviving surrogate caregivers who were aware of or involved in ACP for their loved one reported lower anxiety, depression, and stress levels after their family member's passing than those in the control group. Family members who clearly understand their loved one's wishes are more likely to have a positive end-of-life experience (Andreassen et al., 2017; Detering et al., 2010). Predetermined care plans reduce surrogates' decision-making burden. IMPROVING ADVANCE DIRECTIVE EDUCATION 6 Diversity of Population and Project Site The Sarah Daft Home is a nonprofit assisted living facility located in downtown Salt Lake City. The residents living here are generally over 60 years old, and their length of stay ranges from approximately one month to several years. Most of the patients are ethnically Caucasian males and females. The facility does not accept payment from commercial insurance, Medicare, or Medicaid; therefore, residents pay out of pocket for all services. Facility residents and their family members are the target population for this project. Currently, the residents at Sara Daft are not required to have an advance directive. ACP conversations do not take place unless a patient specifically requests them. The only nurse on staff is not trained or certified in ACP conversations but offers general medical oversight. Certified nursing assistants or med techs perform daily care and medication administration. Significance for Practice Reflective of Role-Specific Leadership The past two years have amplified the critical need for all patients to participate in advance care planning. This project uses evidence-based findings that improve conversations about advance directives and promote advanced, patient-led decision-making. Furthermore, the Patient Self-Determination Act states that healthcare institutions receiving Medicare or Medicaid reimbursement must discuss advance directives with patients (Miller, 2017). Although the Sarah Daft facility is not subject to Medicare or Medicaid regulation, the director of the Sarah Daft Home has indicated a desire to integrate this practice into the facility's policies and procedures. Furthermore, an analysis of the literature supports the implementation of this project. Literature Review and Framework A review of evidence in the literature indicates that people who have identified their wishes for end-of-life treatments have an improved quality of life, increased autonomy at the end IMPROVING ADVANCE DIRECTIVE EDUCATION 7 of life, and decreased use of emergency care (Andreassen et al., 2017; Detering et al., 2010; Lum & Sudore, 2016). However, despite the evidence favoring ACP conversations, patients, caregivers, and clinicians remain unsure how to initiate these discussions (Taneja et al., 2019). These feelings of uncertainty result in delayed conversations until emergencies arise (Druwé et al., 2020). Conversely, meaningful conversations between patients, families, and providers establish clear patient-initiated care goals before a significant medical crisis (National POLST, 2021; Talebreza & Hoffman, 2018). The purpose of this project is to use evidence to propose, implement, and evaluate an educational model system for patients and their families regarding advance directives in an assisted living setting. Search Methods The literature search included the following databases and search engines: CINAHL, Google Scholar, PubMed, and EBSCO. Inclusive terms used for the search included advance directives, end-of-life, surrogate decision-makers, end-of-life conversations, advance care planning, living will, POLST, life-sustaining treatment, what matters most, palliative care, hospice, advance care planning, advance directives, barriers, and nurse practitioners. Search criteria excluded articles older than ten years. Advance Care Planning Increased awareness of ACP has been happening since the 1990s when the Federal Patient Self-Determination Act was enacted. The act mandates that advance directive conversations occur in long-term care, home health, post-acute rehabilitation facility, inpatient hospital settings, and other Medicare-funded programs (Miller, 2017). Since then, many national and local resources have become available to assist people with ACP. The National Institute on Aging (2018) recommends ACP occur at any age or with significant health changes. IMPROVING ADVANCE DIRECTIVE EDUCATION 8 Furthermore, the Centers for Disease Control and Prevention (n.d.) indicate that the fundamental purpose of ACP is to create understanding and completion of advanced directives among the public. Additionally, Lum and Sudore (2016) suggest that ACP conversations ideally lead to a written advance directive that aligns with the patient's medical care preferences. While the Patient Self Determination Act requires medical institutions to give patients information regarding advance directives, the completion rates remain around 18%-31% (Miller, 2017). Furthermore, the National Institute on Aging (2018) states that these forms are voluntary and are never a prerequisite for receiving treatment. Medical personnel need to use these documents as the foundation for patient-driven care. Advanced directives consist of a class of written documents, such as a living will, physician's order for life-sustaining treatment (POLST), or durable power of attorney. These documents outline a patient's desired treatment plan for medical emergencies, such as if they are unable to communicate them (Lum & Sudore, 2016; Miller, 2017) personally. Advance directive forms vary from state to state, but Utah's most frequently used forms are the POLST and living will. The POLST constitutes a physician's order for medical treatment in emergent situations and is effective across healthcare settings (National POLST, 2021). Living wills also clarify specific life-sustaining treatment measures like intubation, defibrillation, and long-term artificial nutrition. Both POLSTs and living wills give the option to designate surrogate decision-makers to ensure adherence to patients' wishes if they become incapacitated. Patients can complete living wills by having a witness sign to verify the document. However, completion of POLST forms must be led by a qualified medical professional such as a nurse, social worker, or physician. The POLST document is considered legal only after the patient or surrogate and the primary medical provider sign it (National POLST, 2021). IMPROVING ADVANCE DIRECTIVE EDUCATION 9 Impact of Advance Care Planning Advance care planning improves quality of life, promotes patient autonomy, and decreases healthcare resources. Lum and Sudore (2016) showed that patients who participated in ACP reported higher indicators of happiness and peace than those who did not participate in ACP. Additionally, Andreassen et al. (2017) noted that family members who clearly understand their loved one's wishes more often report a positive end-of-life experience with their loved one. Furthermore, Detering et al. (2010) related that surviving surrogates described lower anxiety, depression, and stress levels after their family member's passing. Moreover, patient and family satisfaction was higher among those who had participated in ACP. Predetermined care options take the decision-making burden off surrogates and facilitate a greater understanding of patient wishes and goals for their care. Many people fear losing autonomy as they age and become dependent on others. ACP allows patients to make informed care decisions before becoming incapacitated (Lum & Sudore, 2016). Talebreza and Hoffman (2018) encourage open conversations that elicit discussion about medical preferences and allow patients to maintain a sense of control over managing their personal affairs. Stanford University (2021) and The National POLST paradigm (2021) have designed conversation guides to help patients express what matters most to them. These programs focus on having meaningful conversations with family, friends, and providers, ensuring follow-through of patient wishes. Additionally, these programs advocate for patients to designate a surrogate decision-maker who is fully informed of their preferences and will carry them out. Appropriate delegation of a surrogate increases the likelihood that patients' wishes will be honored into their final days. IMPROVING ADVANCE DIRECTIVE EDUCATION 10 The use of emergency medical services at the end of life is lower among patients with advanced directives. In a qualitative follow-up interview study, Andreassen et al. (2017) found that patients who outline end-of-life treatment more often opt out of intensive care treatment, hospitalizations, and extreme lifesaving measures. Similarly, Lum and Sudore (2016) found that cardiac patients with advance directives were more likely to choose comfort-oriented care. Conversely, Druwé et al. (2020) noted that when patients' wishes are not determined in advance, they are more likely to receive full resuscitative and invasive treatments. Dube et al. (2015) suggested that extensive measures frequently occur for older adults near the end of life because patients and families must make critical decisions during stressful situations. Accurately representing patient wishes is diminished when advance directive conversations happen during emergencies. Making medical care decisions in advance improves the likelihood of fewer invasive and heroic measures. Barriers to Advance Care Planning Providers. Licensed clinical staff frequently cite a lack of education about ACP forms and conversation skills as reasons they avoid difficult conversations (Detering et al., 2010; Izumi et al., 2019; Taneja et al., 2019). In addition, Detering et al. (2010) describe common barriers providers have regarding ACP: lack of personal education and time, confidence, commitment, and hesitancy. Similarly, many nurses are reluctant to have ACP conversations believing they are out of their scope of practice and that patients will not want to discuss ACP options. Izumi et al. (2019) noted that nurses avoid ACP discussions because they desire to maintain a sense of hope, feel poorly trained, and perceive a lack of information. However, The American Nurses Association (2016; 2020) has identified advance care planning well within the role of nurses. IMPROVING ADVANCE DIRECTIVE EDUCATION 11 Dube et al. (2015) conducted a quantitative nonexperimental descriptive design study involving nurse practitioners (n = 160). They identified time and resources as significant barriers to facilitating ACP discussions with patients. Additionally, a quasi-experimental study by Wissow et al. (2004) found that when primary care providers (n = 29) were both educated on and reminded to address advance directives, they had higher rates of completed advance directives among their patients. Furthermore, the providers in the study reported similar barriers of time and unwillingness to discuss advance directives with patients. Patients. Approximately 50% of people will require someone else to make decisions for them at the end of their life (Lum & Sudore, 2016). In a grounded theory study of older adult patients, Taneja et al. (2019) found that many patients avoided ACP conversations assuming surrogate decision-makers already knew their wishes. In many cases, this belief was held without the patient and surrogate previously engaging in any significant discussion regarding end-of-life medical treatment preferences. Likewise, Buss et al. (2017) suggested that even after conversations with their providers, many patients still do not fully understand the severity of their disease process and will not want to engage in ACP. Taneja et al. (2019) found that personal religious beliefs, education, and income significantly influenced a person's comfort level with discussing and completing advance directives. Furthermore, Aaronson et al. (2020) concluded that many patients draw on their life experiences and anecdotes from friends when formulating their care preferences instead of making informed decisions. Advance Care Planning Conversations Navigating ACP conversations requires skill, training, and practice. Talebreza and Hoffman (2018) suggest tailoring ACP conversations to patients based on their comfort level, knowledge, and preferences. Likewise, it is common for physicians, nurse practitioners, nurses, IMPROVING ADVANCE DIRECTIVE EDUCATION 12 or social workers to facilitate these discussions individually or together (National POLST, 2021). Interprofessional collaboration is the most successful approach to increasing the completion rate of advance directives (Aaronson, 2020; Izumi et al., 2019). Moreover, Clark et al. (2017) found that women with cancer who had more than one provider talk to them about ACP were more likely to complete an advance directive. Providers are responsible for creating meaningful conversations between themselves and patients to determine goals of care. The overall purpose of life-sustaining treatment conversations is to recognize personal values and present health status to formulate personalized treatment goals (Talebreza & Hoffman, 2018). These conversations consider the capacity of the patient to make their own decisions or involve a surrogate if needed. During ACP conversations, it is crucial to recognize how patients perceive their health status and prognosis and help them understand what treatment options are available to meet their goals. Furthermore, providers facilitating these discussions should be empathetic and elicit clarification of vague responses, allowing the patient to determine what matters most and formulate it into a written directive (Talebreza & Hoffman, 2018). Meaningful ACP conversations between patients and providers result in clear patient-driven goals of care. Advanced practice nurses are well suited for ACP discussions. Dube et al. (2015) found nurse practitioners who had more time to discuss wishes and focused on advance directive training were more likely to have ACP conversations. Furthermore, they determined that a lack of facility resources negatively impacted the number of exchanges. Likewise, Wissow et al. (2004) performed a yearlong quasi-experimental trial implementing an educational curriculum for primary care providers to promote advanced care directive completion in older adult patients (n = 2,120). They found that providers with specialized education on ACP had 7.8% of their IMPROVING ADVANCE DIRECTIVE EDUCATION 13 patients complete new advance directives compared to less than 1% of the control group (p < .001). Providers should learn to initiate conversations about end-of-life wishes with their patients. Conversely, in a systematic review and meta-analysis of available communication tools for healthcare providers regarding advance directives, Chung et al. (2016) found that these tools do not produce adequate communication skills needed for end-of-life conversations. Moreover, while learners understood why these conversations were significant, most continued to lack the skills to carry them out. Hodgson et al. (2004) discussed how social workers and chaplains bridge this gap by being well-versed in complex conversation skills. Patient and Family Education on Advance Care Planning Advance medical care decisions are profoundly personal and influenced by various individual beliefs, experiences, and values. Andreassen et al. (2017) found that families who understand their loved ones' wishes report a higher level of peace of mind and positive end-of-life experiences. Similarly, Detering et al. (2010) supported these findings by suggesting that surviving surrogates had lower instances of anxiety, depression, and regret after their family member passed away. Additionally, they found that for those who participated in ACP and passed away during the study (n = 56), end-of-life wishes were more likely to be known and followed when compared to the control group (p < 0.001). The Stanford Medicine (2021) letter project empowers patients to overcome hesitancy by offering templates they can fill out and give to their families and physicians. These templates help patients quantify their wishes in meaningful ways focusing on what constitutes a high quality of life for them. Patient education on end-of-life treatment options by healthcare providers supports patient-centered care and autonomy. IMPROVING ADVANCE DIRECTIVE EDUCATION 14 Discussions about advanced treatment options and life-prolonging care allow patients to make informed decisions about their care and help reduce false assumptions. Poor understanding of medical terminology, outcomes, and procedures can create inaccurate treatment options and prognosis beliefs. For example, in a survey of patients waiting in an emergency room (n = 500), Bandolin et al. (2020) report that more than half of participants estimate CPR success rates to be 75% in all circumstances. Additionally, more than 95% of participants in the survey by Bandolin et al. report television as their primary source of information about CPR. Conversely, Goodarzi et al. (2014) find that in-patients who had received CPR (n = 320) age 12-69 years old, the initial success rate of return of heartbeat was 15.3% (n = 49) with only 10.6% (n = 34) successfully discharged from the hospital. Additionally, Druwé et al. (2020) report similar findings in a subanalysis study of CPR performed in adults aged 80 and older (n = 536); only 11 patients survived to discharge from the hospital. Taneja et al. (2019) add that advanced discussion of healthcare options reduced intensive care admission rates and associated costs by avoiding burdensome lifesaving measures. Discussions about advanced treatment options and life-prolonging care allow patients to make informed decisions about their care and reduce false assumptions. The literature suggests interprofessional collaboration is the most successful approach to increasing the completion rate of advance directives (Aaronson, 2020; Clark et al., 2017; Izumi et al., 2019). Clark et al. found that women with cancer who had more than one provider talk to them about ACP were more likely to complete an advance directive (2017). Additionally, ACP programs have demonstrated that a coordinated, organized, patient-centered approach led by trained mediators can enhance patient outcomes (Detering et al., 2010). Patient-centered care is IMPROVING ADVANCE DIRECTIVE EDUCATION 15 optimal in a modern healthcare system. Programs with a patient-centered ACP program are generally more successful in helping patients verbalize their wishes (Detering et al., 2010). Framework This quality improvement project focuses on the IOWA model as a framework for practice. This model represents an evidence-based and patient-centered guide to identifying and implementing change within the healthcare setting. The IOWA model consists of seven steps: identify a problem, form a team, retrieve and grade evidence, develop an EBP standard, implement the EBP, and evaluate the results. The identified problem involves residents at an assisted living facility who lack completion of advance directives. The team's synthesis and appraisal of evidence recognize the need for providers to facilitate advance directive paperwork with patients. A simple pilot program will consist of a "what matters most" conversation with two patients and the next of kin. A focused discussion will occur regarding personal preferences for care as outlined in current advance directive paperwork for the State of Utah. The team will implement the program facility-wide after adjustments are made based on participant feedback. Once the education program is operational, frequent feedback, analysis, and evaluation are necessary. Discussion Like any learned clinical skill, effective communication takes training and practice. Evidence shows that providers and patients have personal hesitancy about ACP discussions (Druwé et al., 2020; Taneja et al., 2019). Increased knowledge and training for healthcare professionals help them become familiar with ACP tools. Patients need to understand end-of-life treatment options and express what matters most to them. While a large portion of the evidence identifies only benefits and barriers to advance care planning, further research needs to be IMPROVING ADVANCE DIRECTIVE EDUCATION 16 completed regarding the effectiveness of education training models for current providers to prepare clinical staff to lead ACP conversations. Skill-based programs, such as role-playing or scripted dialogue, may offer providers the opportunity to practice complex conversations and improve conversation competency. Implications for Practice With a surging pandemic in 2020 that flooded hospitals with critically ill patients, many family members were left unprepared to make lifesaving medical decisions for their loved ones (Aaronson et al., 2020). Having conversations about advanced care treatments is recommended for patients of all ages. Clinicians are responsible for helping patients and their families make informed decisions about their care before an emergency. Moreover, the evidence supports incorporating a comprehensive ACP education program for patients into care settings. Trained staff can help patients begin to have meaningful conversations with their families about decisions related to their care. A comprehensive advance directive education program promotes patient-centered healthcare. Project Plan This project was a quality improvement process designed to implement a new practice intervention about advance directive education. No process existed for educating residents at the Sarah Daft Home about advance directives. The facility director had identified this as a gap in their system that needed improvement. The key outcome of this project was to focus on achieving increased numbers of completed advance directives within the facility population. A process improvement dictated the need for continual monitoring of outcomes by facility staff to evaluate the effectiveness of advance directive teaching and completion over the next three months. After this time, the administration and staff discussed any needed changes to the IMPROVING ADVANCE DIRECTIVE EDUCATION 17 process. Outlined below includes project design details with instruments, needs assessment, sustainability, and ethical considerations. Project Design The plan for this project consisted of creating a process to educate, complete, manage, and sustain advance directives within the Sarah Daft Home, reflecting the quality improvement design. This process focused on educating residents and their families about advance directive paperwork from the state of Utah and measuring whether their attitudes had changed. This project aimed to increase the number of patients with ACP paperwork in an assisted living population. Needs Assessment of Project Site and Population The gap within the Sarah Daft Home was a lack of assistance and education of residents and their families regarding AD paperwork completion. The administrative department would like to increase the number of residents with completed advance directives by offering an education class on AD paperwork upon admission. This project allowed current residents and family members to participate in an educational learning session designed to increase their access to and knowledge of ADs, thereby potentially increasing the number of residents with completed forms. Facilitating access to these services and acting as a reliable resource throughout the care process helped facility leaders support patients who otherwise find it challenging to access them. Cost Analysis and Sustainability of Project Managing a budget for the program was affordable and occurred at minimal to no additional cost to the facility. The AD workshop was taught in the facility common room, where many of their activities already take place. Access to learning material used in the workshop was IMPROVING ADVANCE DIRECTIVE EDUCATION 18 made available to staff, residents, and family members via a QR code. Copies of pre- and post-teaching surveys and the Utah Advance Health Care directive were printed on-site. The program's sustainability relied on staff to keep current copies of the forms available and integrate advance directive teaching into the facility admission process. These processes were sustained by creating a new facility policy. Project Outcomes This project aimed to create an ongoing advance directive education program for the Sarah Daft Home Assisted Living Facility. In collaboration with another DNP-FNP student, residents and staff participated in classes on completing advance directives. Current staff was trained to assist residents in filling out an advance directive. Residents learned about crucial details of the Utah Advance Healthcare Directive. A policy gap was identified and resolved by establishing a standard protocol for staff to follow. Now residents are offered advance directive assistance upon admission and during their stay at the facility. These project outcomes have remained consistent through the implementation of the project. Consent Procedures and Ethical Considerations Several measures were taken to protect the welfare and rights of participants in this project. First, IRB approval was obtained before implementing the process improvements. Additionally, as stated in the surveys, each participant gave informed consent to participate in the project. Basic demographics were obtained from the surveys; however, the anonymity of each participant was ensured since no personal health information was obtained. Pre- and post-teaching surveys were kept in a locked box at the facility. Furthermore, participation in the teaching was voluntary. IMPROVING ADVANCE DIRECTIVE EDUCATION 19 Instruments to Measure Intervention Effectiveness Two instruments were developed for this project: pre- and post-teaching surveys (see Appendix A and B). These surveys were created based on Harvard University guidelines for survey research (Harrison, 2007). They were available in English and Spanish to accommodate the target audience's needs. They measured patient and family attitudes, feelings, and knowledge of advance directives. The survey results were reported using aggregate data, ensuring anonymous and confidential responses. Data from these surveys were used for educational purposes to improve course content in the future. Project Implementation The outlined section reflects project implementation, supporting a practice change. A description of the details includes setting and AD educational presentation, with sustainability processes. Moreover, measurement of implementation effectiveness is discussed. Project Intervention The project intervention utilized pre-established educational content and project-specific deliverables. Participants gathered in a group setting at the Sarah Daft Home common room. Individuals were allowed to complete the optional pre-teaching survey with demographic information and seven questions to assess current attitudes toward advance directives (see Appendix A). Participant responses were kept anonymous without any identifying personal information. Additionally, the facilitator gave each participant a copy of the Utah Advance Healthcare Directive Form. Participant education consisted of a prerecorded video podcast lecture from the Utah Commission on Aging (2021) (see Appendix C). Participants were directed to the Utah Advance Health Care Directive as related topics were presented (see Appendix D). Additionally, the IMPROVING ADVANCE DIRECTIVE EDUCATION 20 facilitator paused the video to discuss and answer questions at various intervals—the format of following along and discussing encouraged participants to understand each section before moving to the next. After the video teaching was completed, a final question and answer session was performed, and participants were offered assistance to complete a copy of the advance directive if desired. Finally, post-teaching surveys were distributed to participants to evaluate whether attitudes toward AD changed (see Appendix B). Teaching took place on March 4, 2022. The participants completed surveys before and after the AD workshop. After the workshop, the facility champion conducted chart audits in April, May, and June at approximately one-month intervals. Chart audit results were stored in a locked office cabinet of the facility nurse. Furthermore, participant feedback from the AD workshop was incorporated into the program to identify areas for improvement. Survey results, chart audits, and informal feedback from staff, administrators, residents, and residents' families helped identify if the education session increased the number of completed advance directives within this population. A two-page brochure was created for admission paperwork packets with basic AD information (see Appendix E). The brochure includes a link to the Utah Commission on Aging video podcast shown during the educational session. The facility champion maintains the original copy of the brochure for future use. The facility director selected the champion to ensure sustainability through integration into facility policy. Project Timeline The development and completion of this project happened over 14 months. A thorough literature review of evidence-based practices was conducted in the Summer of 2021, with IRB approval for the project obtained in Fall 2021. Implementation occurred on-site at the Sarah Daft IMPROVING ADVANCE DIRECTIVE EDUCATION 21 Home on March 4, 2022. The project was completed in the Summer of 2022, and dissemination happened in the Fall of the same year (see Appendix F for a complete timeline of events). Project Evaluation Residents and families at the Sarah Daft Home Assisted Living facility in Salt Lake City, Utah, participated in an hour-long educational session discussing advance directives. Five residents and one family member participated in the session, with three that chose to complete pre-and post-teaching surveys. The surveys consisted of a 7-question Likert-type scale evaluating knowledge and attitudes about advance directives. The goal was to determine if providing an educational session about advanced directives would improve participant knowledge and attitudes about advance directives, as shown by the survey results. Data Maintenance/Security Completed paper surveys were stored in a locked cabinet with the facility nurse. Survey results were analyzed and stored on a password-protected computer. Results were anonymous, and completing demographic information and surveys was optional. Data Collection and Analysis Physical copies of pre- and post-surveys were distributed to participants before and after the teaching session. Survey results were analyzed using Excel. Due to the limited number of participants, data were reported in percentages. Pre- and post-surveys varied slightly and were available in English and Spanish (see Appendix A). The pre-survey results outlined participant demographics (see Appendix G). During the educational session, participants gauged their knowledge of advanced directives and how to complete and update paperwork. Additionally, participants indicated if they had already completed an advance directive, which none of them had. Furthermore, the IMPROVING ADVANCE DIRECTIVE EDUCATION 22 survey asked participants to rate their confidence that their end-of-life wishes would be followed. Last, they ranked their level of support for advance directives for those who could not choose for themselves (see Appendix H). Findings Overall, the survey indicated that providing education on advance directives increased the knowledge level of participants about advanced directives. In the presurvey, none of the participants rated their knowledge of advance directives as somewhat knowledgeable; however, 66.7% of participants agreed with this rating post-teaching. Similarly, 100% of participants strongly supported advance directives for people who could not make decisions for themselves, compared to 66.7% who somewhat supported them before teaching. While none of the participants completed an advance directive immediately after the teaching session, post-survey results indicated that 100% of participants probably would or definitely would complete an advance directive in the future (see Appendix H). Strengths The project was cost-effective. Teaching materials from existing Utah advanced care planning resources were utilized. The project has the versatility to be used in a variety of healthcare settings. Weaknesses The sample size of this project was small. Only three participants completed surveys. Participants were all White, despite the teaching being offered to all ethnicities. The reliability of these results should not be generalized to the public due to these limitations. IMPROVING ADVANCE DIRECTIVE EDUCATION 23 Quality Improvement Discussion The results of this project support evidence in favor of advance directive education at an assisted living facility. Patient understanding of advance directives increased during a formal education session between provider and patient. Advance directives should be a part of every patient record. Participants of this program increased their knowledge about advance directives and the likelihood of completing an advance directive. Healthcare providers are essential to these discussions and should consider integrating an advanced care planning program into their policies and practice. Translation of Evidence into Practice This project supports findings that educating providers and patients about advance directives improves patient understanding and paperwork completion rates. Most patients in the project education session about advance directives reported they were more likely to complete an advance directive. Similarly, they reported higher levels of understanding of the advanced directive forms. These outcomes support previous literature on the issue. While advance directive completion and discussion are underutilized in the healthcare system, this project promotes patient engagement in education to improve understanding of advance care completion. Furthermore, addressing these complex issues within the assisted living setting allows providers to educate a vibrant population of aging adults before emergencies arise. This knowledge supports implementing advance directive education programs in assisted living settings. Implications for Practice and Future Scholarship Moving forward, advance directive education and completion should be central to every patient care plan. Assisted living facilities should be held to the same standard as government-funded facilities and be required to ask every patient about an advance directive. Efforts should IMPROVING ADVANCE DIRECTIVE EDUCATION 24 be made to create and improve provider and patient education programs that facilitate honest discussions about end-of-life care wishes. These practices can reduce the medical burden on the aging population and help restore dignity, quality, and autonomy at the end of life. Education programs directed at healthcare providers and patients would be most beneficial. Further studies are suggested to explore the impact of having integrated advance care planning professionals on-site within an assisted living facility. In addition, studies should be performed to examine the benefits of advance care planning and teaching and their effects on providers. Sustainability The materials used in this project were made available to the Sarah Daft Home administrator and nursing staff for future education sessions. Additionally, the Sarah Daft Home has chosen to integrate a facility policy and procedure about advance directives to ensure sustainability and consistency. Dissemination The results of this project were disseminated in a formal poster and podium presentation to the Weber State University Annie Taylor Dee School of Nursing faculty and students in the Fall of 2022. Additionally, this manuscript is available in the Weber State University Stewart Library Doctoral Project Repository. Conclusion End-of-life conversations are difficult for providers and patients. These conversations often get postponed until a crisis happens. Delaying these conversations often burdens caregivers, family, and providers unnecessarily. Healthcare professionals are responsible for leading these conversations and focusing on what matters most to the patient. Using current education programs and materials, facilities and providers can offer better resources to families IMPROVING ADVANCE DIRECTIVE EDUCATION 25 and patients. Advance care planning conversations require practice and time. Educating patients and families on paperwork requirements can help them make informed decisions and improve the likelihood of completing an advance directive before an emergency occurs. Providers should reflect on how they can improve their education on advance directive conversation and become familiar with their state forms. Furthermore, they should discuss how an advance directive education program could be integrated into their workplace. IMPROVING ADVANCE DIRECTIVE EDUCATION 26 References Andreassen, P., Neergaard, M. 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Older people projected to outnumber children for the first time in US history. Department of Commerce, Economics and Statistics Administration. https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html Utah Commission on Aging. (2021, December 16). Part-2 Advance care planning-advance directives [video]. YouTube. https://www.youtube.com/watch?v=n40A7ad3ua0&t=1s Wissow, L. S., Belote, A., Kramer, W., Compton-Phillips, A., Kritzler, R., & Weiner, J. P. (2004). Promoting advance directives among elderly primary care patients. Journal of General Internal Medicine, 19(9), 944–951. https://doi.org/10.1111/j.1525-1497.2004.30117.x IMPROVING ADVANCE DIRECTIVE EDUCATION 31 Appendix A Advanced Directives and Life-Sustaining Treatment Education Course The Sarah Daft Home Elise Butterfield, BSN, RN, DNP Student Weber State University School of Nursing Learning Content: 1. Discuss my end-of-life care preferences with my family. 2. Describe how to update or make changes to a current advance directive. 3. Complete Utah Advance Care Directive for self or family member. The following is a paper survey that takes approximately 5 minutes. The survey questions will be about your feelings and knowledge surrounding advance directives. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of this survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact Elise Butterfield at elisenelson@mail.weber.edu. Demographics: Directions: Please choose the answer that best describes your situation 1. Which category below includes your age? 49 or younger 50-60 61-70 71-80 81-90 90+ 2. Do you consider yourself White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or some other race (please specify)? 3. What is your gender? Female Male Other (specify) 4. Are you currently married, widowed, divorced, separated, or never married? IMPROVING ADVANCE DIRECTIVE EDUCATION 32 Pre-Teaching Assessment: Directions: Please choose the answer that best describes your situation. 1. I am knowledgeable concerning advance directives and end-of-life care options. Very knowledgeable Somewhat knowledgeable Neutral Somewhat unknowledgeable Unknowledgeable 2. I have completed an advance directive. Yes No 3. I have not completed an advance directive, but I am likely to complete one. Definitely will Probably will Neutral Probably will not Will not 4. I have discussed my end-of-life care preferences with my family in the last 12 months. Yes No 5. I am confident that my loved ones would follow my healthcare wishes if medical decisions had to be made on my behalf. Very confident Somewhat confident Neutral Somewhat unconfident Unconfident 6. I feel confident on how to update or make changes to a current advance directive. IMPROVING ADVANCE DIRECTIVE EDUCATION 33 Very confident Somewhat confident Neutral Somewhat unconfident Unconfident 7. I support advance directives for a person who cannot make decisions for themself. Strongly support Somewhat support Neutral Somewhat do not support Do not support IMPROVING ADVANCE DIRECTIVE EDUCATION 34 IMPROVING ADVANCE DIRECTIVE EDUCATION 35 IMPROVING ADVANCE DIRECTIVE EDUCATION 36 IMPROVING ADVANCE DIRECTIVE EDUCATION 37 Appendix B Surveys Advanced Directives and Life-Sustaining Treatment Education Course The Sarah Daft Home Elise Butterfield, BSN, RN, DNP Student Weber State University School of Nursing Learning Content: 1. Discuss my end-of-life care preferences with my family. 2. Describe how to update or make changes to a current advance directive. 3. Complete Utah Advance Care Directive for self or family member. The following is a paper survey that takes approximately 5 minutes. The survey questions will be about your feelings and knowledge surrounding advance directives. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of this survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact Elise Butterfield at elisenelson@mail.weber.edu. Post-Teaching Assessment: Directions: Please choose the answer that best describes your situation. 1. I am knowledgeable concerning advance directives and end-of-life care options. Very knowledgeable Somewhat knowledgeable Neutral Somewhat unknowledgeable Unknowledgeable 2. I have completed an advance directive. Yes No 3. I have not completed an advance directive, but I am likely to complete one. IMPROVING ADVANCE DIRECTIVE EDUCATION 38 Definitely will Probably will Neutral Probably will not Will not 4. I am confident my loved ones would follow my healthcare wishes if medical decisions had to be made on my behalf. Very Confident Somewhat confident Neutral Somewhat unconfident Unconfident 5. I feel confident on how to update or make changes to a current advance directive. Very confident Somewhat confident Neutral Somewhat unconfident Unconfident 6. I support advance directives for a person who cannot make decisions for themself. Strongly support Somewhat support Neutral Somewhat do not support Do not support 7. How well did the Advance Directive presentation provide adequate information for you to complete the Utah Advance Care Directive? Very well Somewhat well Neutral Somewhat Not at all IMPROVING ADVANCE DIRECTIVE EDUCATION 39 8. Is there any other information about advance directives that interest you but was not included in this presentation? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IMPROVING ADVANCE DIRECTIVE EDUCATION 40 IMPROVING ADVANCE DIRECTIVE EDUCATION 41 IMPROVING ADVANCE DIRECTIVE EDUCATION 42 Appendix C Advance Directive Video Presentation https://youtu.be/n40A7ad3ua0 https://ucoa.utah.edu/coreissues/directives/index.php IMPROVING ADVANCE DIRECTIVE EDUCATION 43 Appendix D Advance Directive Form IMPROVING ADVANCE DIRECTIVE EDUCATION 44 IMPROVING ADVANCE DIRECTIVE EDUCATION 45 IMPROVING ADVANCE DIRECTIVE EDUCATION 46 IMPROVING ADVANCE DIRECTIVE EDUCATION 47 Appendix E Patient Handout for New Admissions at the Sarah Daft Home How Healthcare Changes Over Time This diagram from the National POLST Paradigm (2022) depicts how health can fluctuate over time and when using an advance directive form is most suitable. While most people are in Stage 1 or Stage 2, it is appropriate for anyone over 18 years old to have an advance directive. Regardless of age (except in a couple of states), a POLST is appropriate in Stage 3. (POLST is a medical order completed by the patient’s provider.) *The line depicts your general health over a life span. Advance Care Planning For over 100 years, the Sarah Daft Home has been committed to providing affordable, high-quality care in a homelike setting. As individual healthcare needs change over time, we encourage residents and families to consider what matters most to them. As a courtesy to you, we offer qualified assistance to complete advance directive forms. IMPROVING ADVANCE DIRECTIVE EDUCATION 48 Advance Directives • The purpose of advance directives is to legally identify an individual you wish to make medical choices for you if you are unable to communicate or engage in such conversations. This individual is known as a surrogate. • This document may be known as an advance directive, living will, or health care power of attorney. • These documents can gather information on individual values, religious views, hobbies, and general healthcare treatment preferences. Surrogate/Healthcare Proxy • The surrogate is the individual designated to make medical choices for you if you are unable to communicate. In an advance directive, you legally nominate this individual. • This individual may be referred to as a surrogate, a proxy, a health care power of attorney, or a decision-maker in your state. • In most states, if you are unable to communicate, your provider will speak with this person about generating or amending your advance directive or POLST forms. 6 D’S OF ADVANCE CARE PLANNING Scan the QR code below for more information on Advance Care Planning from the Utah Commission on Aging. The Utah Commission in Aging recommends revisiting your advance directives after any of these events: • Decade (over 10 years since you last filled one out) • Death (spouse or healthcare proxy has passed away) • Divorce • Diagnosis (new illness or cancer) • Decline in health IMPROVING ADVANCE DIRECTIVE EDUCATION 49 IMPROVING ADVANCE DIRECTIVE EDUCATION 50 IMPROVING ADVANCE DIRECTIVE EDUCATION 51 Appendix F Overall Project Timeline Timeline for Project Implementation and Completion Summer 2021 • Gather literature related to advanced directive education programs and resources -June 2021 • Meet with department heads and clinical staff to discuss current procedures and design future implementation model—June 2021 • Identify a team champion to establish a sustainable advance directive program—July 2021. • Project proposal approval by project consultant- June 2021 • Complete Project Proposal— August 9, 2021 Fall 2021 • Present Project Proposal for approval. • Obtain IRB approval for the project. • Complete all documents, identification or creation of instruments, and/or presentations that are essential for project implementation. Spring 2022 • Begin project implementation March 4, 2022. • Interval chart audits April, May, and June. Summer 2022 • Complete project implementation June 2022. • Begin project evaluation. Fall 2022 • Complete project evaluation. • Complete project dissemination. IMPROVING ADVANCE DIRECTIVE EDUCATION 52 Appendix G Participant Demographics Table 1 Participant Demographics Characteristics n % Gender Female 1 33.3 Male 2 66.7 Age 61-70 2 66.7 71-80 1 33.3 Marital Status Never Married 2 66.7 No Response 1 33.3 Note: n = 3 IMPROVING ADVANCE DIRECTIVE EDUCATION Appendix H Pre-Post Survey Results Table 2 Pre-Post Survey Results Questions Percent VK SK N SU U 1. Knowledge level of Advance Directive 0 (0) 0 (66.7) 33.3 (33.3) 33.3 (0) 33.3 (0) DW PW N PWN DWN 3. Likely to complete an Advance Directive 33.3 (66.7) 33.3 (33.3) 33.3 (0) 0 (0) 0 (0) VC SC N SU U 5. Confident loved ones would follow my wishes 33.3 (33.3) 0 (66.7) 33.3 (0) 0 (0) 33.3 (0) 6. Understand how to update an Advance Directive 0 (33.3) 33.3 (33.3) 0 (0) 0 (33.3) 66.7 (0) 7. Support Advance Directives S SS N SDNS DNS 0 (100) 66.7 (0) 0 (0) 0 (0) 0 (0) Note: n = 3. Pre-survey results are presented without parentheses, and post-survey results are presented in parentheses. A variety of scales were used. See abbreviations for scales. 1. Very knowledgeable (VK), Somewhat knowledgeable (SK), Neutral (N), Somewhat unknowledgeable (SU), and Unknowledgeable (U). 3. Definitely will (DW), Probably will (PW), Neutral (N), Probably will not (PWN), and Definitely will not (DWN). 5 & 6. Very confident (VC), Somewhat confident (SC), Neutral (N), Somewhat unconfident (SU), Unconfident (U). 7. Strongly support (S), Somewhat support (SS), Neutral (N), Somewhat do not support (SDNS), Do not support (DNS).