Digital Repository Doctoral Projects Fall 2022 Training Staff to Increase Advance Care Planning for Patients and Families at the Sarah Daft Assisted Living Facility Spencer K. Noyce Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Noyce, S. K. (2022) Training staff to increase advance care planning for patients and families at the Sarah Daft Assisted Living Facility 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. ADVANCE CARE PLANNING 1 Training Staff to Increase Advance Care Planning for Patients and Families at the Sarah Daft Assisted Living Facility by Spencer K. Noyce 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 _______________________________ ______________________________ Spencer K. Noyce, 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 Spencer K. Noyce December 16, 2022 ADVANCE CARE PLANNING 2 Abstract The risk for incomplete advance care plans increases when end-of-life conversations do not occur. Identifying key individuals with proper training and education is essential for initiating these difficult conversations. This DNP project aimed to highlight the importance of having regular staff training and frequent discussions about end-of-life planning and increasing the completion of advance directives for all residents at Sarah Daft Assisted Living Facility, leading to better patient outcomes. Purpose: The project aimed to ensure that all residents at the Sarah Daft Assisted living completed an advance directive, so they are prepared to have their choices recognized at end of life. Methodology: This DNP project included gathering the existing advance directive policy, training the staff members, completing a pre- and post-test to see if they learned from the presentation, identifying a champion RN, and checking charts at one-month intervals to ensure completion of advance directives. Results: After the training session, staff members reported an increased knowledge level and felt more comfortable about the content of advance directives, realized the importance of completing advance directives, and felt competent with end-of-life discussions. In addition, post-training surveys indicated that more than 90% of staff members support the advance directives policy. Implications for Practice: This training and advance directive policy implementation helped support the culture change at Sarah Daft Assisted Living, easing the burden for the patients and their family members as they make end-of-life decisions. Keywords: advance directive, end-of-life, living will ADVANCE CARE PLANNING 3 Table of Contents Abstract ........................................................................................................................................... 2 Training Staff to Increase Advance Care Planning for Patients and Families at the Sarah Daft Assisted Living Facility .................................................................................................................. 5 Background and Problem Statement ........................................................................................... 5 Diversity of Population and Project Site ..................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership .............................................. 6 Literature Review and Framework ................................................................................................. 7 Search Methods ........................................................................................................................... 7 Description of Advance Directives ............................................................................................. 8 Benefits of Advance Care Directives .......................................................................................... 9 Barriers to Completed Advance Directives ............................................................................... 11 Solutions to Completed Advance Directives ............................................................................ 13 Advance Directive Education for Staff ................................................................................. 14 Advance Directive Education for Patients and Their Families ............................................. 14 Framework ................................................................................................................................ 15 Discussion ................................................................................................................................. 15 Implications for Practice ........................................................................................................... 16 Project Plan ................................................................................................................................... 16 Project Design ........................................................................................................................... 16 Needs Assessment of Project Site and Population .................................................................... 17 Cost Analysis and Sustainability of Project .............................................................................. 18 Project Outcomes ...................................................................................................................... 18 Consent Procedures and Ethical Consideration ........................................................................ 19 Instruments to Measure the Effectiveness of Intervention ........................................................ 19 Project Implementation ................................................................................................................. 19 Interventions .............................................................................................................................. 20 Project Timeline ........................................................................................................................ 20 Project Evaluation ......................................................................................................................... 21 Data Maintenance and Security................................................................................................. 21 ADVANCE CARE PLANNING 4 Data Collection and Analysis .................................................................................................... 21 Findings ..................................................................................................................................... 23 Strengths ................................................................................................................................ 23 Weaknesses ............................................................................................................................ 24 Quality Improvement Discussion ................................................................................................. 24 Translation of Evidence into Practice ....................................................................................... 24 Implications for Practice and Future Scholarship ..................................................................... 25 Sustainability ......................................................................................................................... 25 Dissemination ........................................................................................................................ 26 Conclusion ................................................................................................................................. 26 References ..................................................................................................................................... 27 Appendix A ................................................................................................................................... 34 Appendix B ................................................................................................................................... 37 Appendix C ................................................................................................................................... 40 Appendix D ................................................................................................................................... 49 Appendix E ................................................................................................................................... 51 Appendix F.................................................................................................................................... 53 ADVANCE CARE PLANNING 5 Training Staff to Increase Advance Care Planning for Patients and Families at the Sarah Daft Assisted Living Facility Advance care planning (ACP) leads to significant end-of-life (EOL) care discussions and decisions (Jeong et al., 2019). Research has shown the experiences of frail and older people in planning their care; however, minimal information remains available on how older adults collaborate with their family members to formulate a plan to meet their needs (Hopkins et al., 2020). Patients and family members need to be educated about making EOL decisions well before an unforeseen health crisis. ACP is a critical component that allows family members guidance when they cannot speak for themselves (Ramsbottom & Kelley, 2014). In addition, educating families about the quality of care during the dying process will lead to better patient outcomes (Verreault et al., 2018). The DNP project focuses on training healthcare staff on ways to educate patients and families about ACP at the Sarah Daft Assisted Living Facility. Background and Problem Statement Centers for Disease Control and Prevention (CDC) reports that 70% of Americans live without an advance directive. Older adults who have one or more chronic diseases need to complete an advance directive, becoming part of the process when managing a chronic illness (Vermunt et al., 2017). Many Americans with chronic conditions can live a joyful, older adult life while experiencing slow declines. However, for some individuals, their health might decline to where they cannot speak or make decisions on their own concerning their healthcare needs (CDC, 2018). In addition, evidence shows that thinking about death is linked to increased EOL collaboration for the terminally ill (Mroz et al., 2020). Therefore, all individuals need advance directives, especially people advancing in age or living with chronic illnesses (Leaving Well Utah, 2019). ADVANCE CARE PLANNING 6 Older adults’ values and choices need to be addressed, and ACP allows these preferences. One of the purposes of ACP is to ensure that people obtain medical care that is agreeable to their values, goals, and intentions during a severe and chronic illness (Sudore et al., 2017). Patient choice is an essential policy in health care for all people, especially those older adults nearing the end of their lives who cannot communicate their desires (Stewart et al., 2011). Gilissen et al. (2017) suggest that long-term care facilities and healthcare professionals are essential in implementing a successful advance care plan. They also share that the staff needs to be willing to be involved in the process, have a solid administrative team monitoring and evaluating the implementation, and have a positive and supportive attitude toward ACP at the facility. In addition, ACP needs a team approach, including new structures, an outlined care delivery process, good attitudes for change, and a definition of the mandatory roles and skills (Gilissen et al., 2017). Diversity of Population and Project Site The project focuses on training the staff at Sarah Daft Assistant Living Facility (ALF), including the medication technicians, nurse, activities director, and executive director. These individuals care for diverse patients, such as low-income, White, Hispanic, and African Americans. The staff relates well with this population and has various races and ethnic backgrounds. Significance for Practice Reflective of Role-Specific Leadership Only one out of three African Americans and one out of two Caucasian individuals have completed advance directives (Bazargan et al., 2021). At Sarah Daft ALF, the current 39-bed facility does not have a well-developed advance directive education or program for the residents. As a result, older patients and families must be prepared and educated about ACP. Lack of ACP ADVANCE CARE PLANNING 7 can lead to undue confusion, stress, and lack of knowledge of resources available to the residents. The need in this community can be addressed by training staff on ways to educate patients and families about ACP. The DNP project aims to provide ACP training by creating one standardized policy and a nurse-driven education protocol that trains staff to educate patients and families about ACP. A literature review outlines the evidence required to develop the policy and protocol for this staff training implementation at Sarah Daft ALF. Literature Review and Framework The literature review and framework section explore evidence-based practice standards on ACP. The following themes emerged from the literature review to help direct the policy development: (a) description of advance directives, (b) benefits of advance care directives, (c) barriers to completed advance directives, (d) solutions to completed advance directives, and (e) ways to promote advance directive completion. The framework used to guide this project is the IOWA model, which focuses on clinical decision-making and evidence-based practice implementation. Search Methods Search terms for this project include advance directive, advance care planning, benefits, barriers, provider, elderly, assisted living facility, acute care, nursing home, race, and minority. Google Scholar was the search engine used to obtain articles, and some of the irretrievable articles in Google Scholar were available in WSU’s databases. Both quantitative and qualitative statistical data were retrieved during the literature review. Most of the evidence showed descriptive data using medians and frequencies. ADVANCE CARE PLANNING 8 Description of Advance Directives Advance care planning leads to a legal document known as an advance directive. The two central portions of an advance directive are the living will and the durable power of attorney for health care. The National Institute on Aging (2018) outlines that EOL preferences are included in the advance directive document and go into effect if patients cannot speak for themselves due to a chronic disease or a sudden injury, regardless of age. In addition, advance directives help family members or legal caregivers know what medical care their loved ones want. Finally, advance directives are meant to promote patients' autonomy and freedom of choice (Trarieux-Signol et al., 2018). Advance directives involve crucial decisions. Some of these decisions include whether the individual wants cardiopulmonary resuscitation, ventilator use, artificial nutrition with a feeding tube, and comfort care. First, the individual needs to consider the kind of treatment they want in a medical emergency. Besides the individual discussing these decisions with their loved ones, it is also beneficial to discuss these options with the physician before recording them in an advance directive. The advance directive discussion aims to enhance mutual understanding among patients, families, and healthcare providers (Chan et al., 2018). An advance directive needs to focus on the individual's preference, such as the quantity of life versus quality of life. Most importantly, the advance directive must reflect what makes life meaningful to the individual (National Institute on Aging, 2018). The National Institute of Aging (2018) outlines that a living will is a specific written document that tells physicians how the individual would like to be cared for if the person is dying, permanently unconscious, or cannot make decisions during an emergency. Content in the living will is specific to what treatment the individual would be comfortable with under certain ADVANCE CARE PLANNING 9 conditions. Furthermore, the durable power of attorney for health care is the legal document that names the individual’s selected person to make medical decisions if they cannot. A durable power of attorney for health care can be chosen instead of completing a living will. Individuals should know what they value and wish for during the EOL treatment. Having these documents in place will help people be prepared for unforeseen events. Finally, signing these documents to make them formal is not essential; the critical component is the communication process and ensuring a mutual understanding between family members and healthcare professionals (Chan et al., 2018). Benefits of Advance Care Directives Miller et al. (2019) indicated that trained registered nurses and doctors can have ACP conversations with patients and their families, leading to better patient outcomes. For example, trained nurses involved with ACP showed remarkable impact on the patients because they explained their preferences, told others what their wishes were, and ultimately lessened the burden on the family members when decisions needed to be made (Miller et al., 2019). In addition, having EOL discussions created a better understanding between the patient and their loved ones or proxy caregiver (Ditto et al., 2021). Finally, evidence showed that EOL discussions improved over time as those healthcare staff had repeated exposure to EOL discussions by observing a provider having that discussion with the patient and family (Rhodes et al., 2015). Jimenez et al. (2018) share that ACP's benefits include more transparent EOL communication, better documentation of the patient's care requests, patients passing away at their chosen place, and overall health cost savings. Mcllfatrick et al. (2018) continue to address ADVANCE CARE PLANNING 10 the benefits of ACP. Having ACP with interventions when the need arises directly affects the caregivers' needs and lessens their burdens through this EOL process. Race and cultural differences also play into whether or not an advance care plan is in place. For example, most Medicare patients of all races or ethnic groups said that if they had a terminal diagnosis, they would choose to die in their own homes and not receive medications or mechanical ventilation to prolong their life. However, respecting patients' wishes, as stated above, is an example of why open and essential conversations about EOL care exist, regardless of people's backgrounds. As a result, patients' and family members' wishes are granted as documented in the advance care plan (Benson & Aldrich, 2012). Evidence also suggests that if providers, patients, and family members are taught about advance directives, follow-up telephone calls for support increased the number of EOL decisions documented in the patient's medical record (Reinhardt et al., 2014). A systematic review by Brinkman-Stoppelenburg et al. (2014) suggests that ACP helps decrease life-sustaining measures. In addition, it increases palliative care and prevents hospitalizations as care was provided in the individuals’ homes. This study reveals that ACP shows an increase in following the outlined EOL wishes. Therefore, ACP positively affects the quality of EOL care the individual receives. Although ACP can be awkward and uncomfortable, many patients reported benefits of ACP (Zwakman et al., 2018). A qualitative study by Stewart et al. (2011) reinforces the significance of ACP education, the benefits of ACP, and the importance of care and caregiving either by staff or families. This study involved 39 older people in care facilities in London. They studied the views of care staff and families about ACP through semi-structured interviews. They focused on three themes: ACP benefits, ACP barriers, and facilitators of ACP discussions. Conducting the interviews with the ADVANCE CARE PLANNING 11 residents’ families, residents, and the care staff increased the overall support of ACP in care homes. Based on this study, educating the care team, residents, and the family about the benefits, barriers, and ACP discussions led to more respect for the resident's wishes and support in their treatment approach. To increase ACP engagement, community‐led ACP education should be coordinated with the healthcare systems and providers to achieve the most significant results (Siden et al., 2021). Barriers to Completed Advance Directives Racial and educational disparities lead to a lack of completion of an advance directive. Completed ACP show that Blacks have the fewest completed and Whites have the highest number completed (Portanova et al., 2017). Completion of an advance directive is linked to older age, more education, and a higher income. Moreover, non-white individuals were less likely to complete an advance directive. Individuals who had a completed advance directive also reported having a chronic disease. Those who did not report a concern with their EOL care were less likely to complete an advance directive (Rao et al., 2014). Patients, family members, and staff commonly lack awareness about ACP, so it is essential to discuss this with providers. The government and the states support advance directives. Still, the patients are not always getting their wishes met by family members or the designated healthcare representative as outlined in their advance directive. Therefore, it is essential to express these wishes to the physician. After all, when patients have an advance directive, only 42% of those individuals have discussed this plan with their primary care physician (Benson & Aldrich, 2012). Discussing advance directives in the primary care office results in a 45% completion rate (Duffield, 1996). ADVANCE CARE PLANNING 12 Nedjat-Haiem et al. (2017) share that society tends to struggle with denial regarding death and dying related to a lack of knowledge or fear of EOL. As such, the EOL wishes get forgotten, go unnoticed, or are not discussed by healthcare providers or family members. Confusion around EOL is another issue people face. Research suggests that there is confusion among healthcare caregivers between EOL care and palliative care, leading to untimely and inconsistent care. If clinical staff members are confused, the resources available are forgotten, and communication between patients, staff, and the family is less effective (Hill et al., 2018). According to Brenner et al. (2020), patients and families want a good quality of life towards the end, but one-third of older adult Americans focus on doing all they can to extend their life, regardless of the poor quality of life. Of the many barriers to completing an advance directive, a lack of physician leadership is one of the most significant factors (Emanuel et al., 1991). Early discussions about palliative care and implementing a plan help with symptom management, communication, and the inclusion of patient-centered care early on. In addition, early ACP conversations help address the needs that people wish for at the end of their life (Benson & Aldrich, 2012). Another barrier noted is that the individuals often do not share their wants or wishes with their healthcare proxy or even know how to tell them what they want at the end of their lives (Morrison, 2020). Evidence suggests that one of the issues with advance directives is the document itself. If the ACP document is unclear, it can be a limiting factor in rolling out an effective advance directive program (Wickersham et al., 2019). Another challenge with advance care planning and advance directives is that it is a document that constantly changes. ACP changing from time to time is normal because life's experiences and the individual's circumstances can change. Bridges et al. (2018) suggest leading a conversation around this topic. A patient should have an engaged ADVANCE CARE PLANNING 13 physician discuss how much easier it will be to have a plan in place, leading to more excellent overall patient and family satisfaction. Caregivers need to be aware of the individual's culture and the languages that they speak. Hong et al. (2018) conclude that it would be wise to implement approaches to ACP and advance directives to the minority populations since this is usually approached heavily by Caucasian health professionals. They continue and suggest that this can be enhanced by recruiting more minorities specializing in this EOL care training (Hong et al., 2018). Evidence also suggests that implementing cultural training as part of the advance directive process helps lower the number of issues with EOL care, as this is a common barrier among patients, families, and providers (Boucher et al., 2021). Solutions to Completed Advance Directives Advance directive completion occurs through education to clinical staff and shows that advance directive promotion and completion rates increase, promoting better attitudes and more excellent knowledge of how this will benefit the patient and their families (Hamayoshi, 2014). A successful way to complete advance directive implementation focuses on educating staff through course enrollment and practical training. Advance directive education is successful when it leads to an improved culture of advance directive knowledge, increased documented conversations about EOL treatments, and recorded preferences of the patients and families. Advance directive education outcomes show that treatments follow patients' wishes more accurately and decrease hospital admissions and deaths. Proper education to the staff can supply them with the knowledge and confidence about advance directives and the essential content and documentation to meet the needs of the patient and family for advance directive completion (Flo et al., 2016). ADVANCE CARE PLANNING 14 Advance Directive Education for Staff The specialized staff expert can implement advance directive education, such as the registered nurse who is knowledgeable and comfortable with conversations about ACP. A suggestion is that all staff members participate in the training by the staff expert. Additional expert trainers, such as the facility social worker, can use a train-the-trainer approach by educating the registered nurse and ensuring they are comfortable and confident in having ACP conversations with the residents. The registered nurse and the staff expert evaluate the staff members’ knowledge and skill about advance directives. (Ampe et al., 2017). In addition, staff members can have essential repeated discussions with residents and families to understand the residents' medical background to help guide the advance directive conversation (Bollig et al., 2016). Advance Directive Education for Patients and Their Families Other interventions for ACP include educating patients and their family members or caregivers and involving them in the ACP discussions (Ampe et al., 2017). Educating patients and their family members can help them navigate EOL conversations with ideas about what to discuss or ask during the conversation. In addition, the education can help patients and their families better understand the EOL needs and how advanced care plans help achieve their loved one's wishes. Their families should be involved in every step of ACP, and the provider and nurse need to engage the family in EOL conversations to help them through that process in time of need (Lopez et al., 2017). Myers et al. (2018) share that the crucial outcome of any teaching or resources provided to the patients and their family members is that their loved ones are given the care desired when the EOL comes. ADVANCE CARE PLANNING 15 Framework The IOWA model is one of several frameworks used to facilitate evidence-based practice in nursing and is the chosen framework for this DNP project. The IOWA model uses seven steps: identify a problem, form a team, retrieve and grade evidence, develop an EBP standard, implement the EBP, and evaluate the results (McClay et al., 2021). First, a problem was identified with a lack of completed advance directives at Sarah Daft ALF. Second, a team was formed, including a co-student, a registered nurse expert, and the administration team. Third and fourth, evidence was retrieved and appraised for desired practice change to train staff to increase the completion of advance directives for patients and families at the Sarah Daft ALF. Fifth, a standard is created and implemented, ensuring each resident and new admission receives the proper training and education to complete an advance directive. The final steps involve implementing and evaluating the new standard and providing patients and their families with the care they wish for near the EOL stages. Discussion Existing literature and evidence show a lack of understanding about advance directives; society struggles with accepting death and dying (Sudore et al., 2017). Implementing a standardized admission process for education and training on an advance directive and how to complete one will improve EOL patient wishes. Educating people early about EOL wishes and ACP and what they offer, including explaining the benefits and barriers, can lead to the completion of more advance directives. Barriers to completing an advance directive are in part due to lack of understanding, lack of knowledge and information, and lack of religious and cultural sensitivity, language barriers, and poor communication skills (Vries et al., 2019). Additional research on completing advance directives at Sarah Daft assisted living can benefit ADVANCE CARE PLANNING 16 other assisted living facilities that wish to implement a standardized process for completing advance directives. Implications for Practice ACP policy standardization improves patient outcomes and reduces poor patient outcomes near the end of life. Developing and implementing one standardized ACP policy and nurse expert-driven education to the staff can reduce the lack of completed ACPs and improve the overall outcome of the patients. In addition, the nurse expert, nurse leadership, and the administrator plan to improve staff compliance with ACP completion during the project's implementation phase. Project Plan This project included creating a standardized advance directive (AD) policy to educate, complete, and manage advance directives, focusing on ALF staff. This project aimed to educate and empower the clinical staff members at the Sarah Daft ALF to feel prepared and confident to lead conversations about end-of-life goals and wishes for their care. In addition, the plan included influencing nurses to follow the established AD policy and completing an AD with every patient. Project Design This quality improvement project aimed to standardize AD completion rates and nurse-driven maintenance in the future. Establishing a standard protocol has driven the staff to ensure all patients have completed ADs. In addition, following Rocky Mountain Cares established AD policy while performing admissions to Sarah Daft reduced nursing practice variability and increased the level of care provided to patients near the EOL. ADVANCE CARE PLANNING 17 Needs Assessment of Project Site and Population This quality improvement project impacted the patients of Sarah Daft ALF. The main participants were the expert registered nurse and the administrator who followed the AD policy and nurse-driven protocols. In addition, ADs quality improvement and completion rates were made possible through stakeholders evaluating pre-post surveys, performing chart audits at 1, 2, and 3 months, and ongoing chart checks at 3-month intervals. Key stakeholders were the staff from the Sarah Daft ALF, including the administrator, registered nurse, med-tech provider, and facility social worker. In addition, they were supported by the corporate offices at Rocky Mountain Care. These stakeholders shared the project's vision to ensure each patient has a completed AD to simply provide the best care to all. The whole purpose of the DNP project was to be more ethical by promoting social justice and educating every staff member on ways to help patients complete their advance directives regardless of diversity or social determinants of health, ensuring their end-of-life wishes. Discussing end-of-life situations and what dying means with patients and their loved ones has been difficult for most caregivers and family members. However, avoiding such discussions has caused the patient and their families to be unaware and unprepared, leading to unethical and unjust end-of-life or dying processes. The goal was to help establish normalcy around end-of-life conversations with staff members at Sarah Daft by combining this into the regular admission process, leading to less anxiety and increasing the patient's level of care as they near the end of their life (Chang et al., 2021). ADVANCE CARE PLANNING 18 Cost Analysis and Sustainability of Project Budgetary requirements for this project have been discussed with the project team and were approved for Sarah Daft's staff education and printing materials. Rocky Mountain Care corporate offices covered the printing costs. Costs included the following: • Education room to meet in for 1-hour training $0 • TV for PowerPoint instruction $0 • Advance directive paperwork/handouts $0 • Printing Handouts $30 covered by Rocky Mountain Care corporate The sustainability plan included incorporating nurse expert education into all new admissions until the new AD implementation was hardwired at Sarah Daft. Additionally, sustainability involved maintaining the printed paperwork/handouts by replacing them as updated practices are identified or as they exhaust supplies to use during the admission process. Project Outcomes The project outcomes were evaluated by measuring the following goals: • Evaluate data from pre-post surveys to assess the effectiveness of the AD policy training • Complete chart audits to ensure advance directives are present at 1, 2, and 3 months • Ongoing chart checks by facility champion at 3-month intervals • Hold monthly meetings by the administrator with the RN, med-tech, provider, and social worker on AD completion rates and policy compliance ADVANCE CARE PLANNING 19 Consent Procedures and Ethical Consideration The Institutional Review Board (IRB) at Weber State University stated that this project meets the requirements for quality improvement and does not require formal IRB approval. Since this quality improvement project lacks human subject testing, IRB approval from Rocky Mountain Care was not needed. Project surveys and results were anonymous, aggregated, and protected in a safe place at Sarah Daft ALF. Instruments to Measure the Effectiveness of Intervention The survey used for the project was adapted from the tool, Measuring the Quality of Palliative Care in the Intensive Care Unit (Levy et al., n.d.). Survey pre-post reflected the AD policy implementation and effectiveness. In addition, the same survey was given to all Sarah Daft employees before and after project implementation to identify their thoughts and attitudes towards ADs and help patients complete them on admission. The results determined if a standardized AD policy increased the number of completed ADs at Sarah Daft ALF. Project Implementation This project was implemented when the standardized AD policy was adopted at Sarah Daft ALF. Sarah Daft's adoption of the policy was critical to the sustainability of this project as this was a new process for the staff and should be built into their daily workflows, making decisions based on the policy. In addition, the education given to the staff members directed the nurse and other leaders of the facility, ensuring the new patients completed ADs. This implementation used a top-down approach from the administrator of Sarah Daft ALF, Paul Ogilvie, but the staff needed to approve the policy and have buy-in to the new workflows. ADVANCE CARE PLANNING 20 Interventions Advance directive education training took place on March 4, 2022. Paul Ogilvie scheduled this meeting for staff who were working that day. Staff members joined together in the activities room, and the length of the education was approximately an hour. The project intervention utilized pre-established evidence-based educational content and project-specific deliverables. First, as the facilitator, I reviewed The Rocky Mountain Care AD policy and answered all questions (see Appendix A). Second, participants were given the opportunity to complete the pre-survey (see Appendix B). Third, the staff was educated about the new AD policy using a PowerPoint presentation (see Appendix C). Fourth, the staff members were given the opportunity to complete the post-survey (see Appendix B). Chart audits were planned under the administrator's directions during the PowerPoint presentation. Finally, after the PowerPoint presentation was completed, a final question and answer session was performed, and staff members were encouraged to ask additional questions. As discussed during the training, the facility champion conducted chart audits in April, May, and June at approximately 1-month intervals. The facility champion, the registered nurse, was chosen by Paul Ogilvie to guide and oversee the chart audits. Chart audit results were stored in a locked cabinet by the registered nurse. The key stakeholders, administrator, registered nurse, and I evaluated pre-post survey results and performed chart audits at 1, 2, and 3 months. After this time, chart audits continued at 3-month intervals under the follow-up of the administrator. In addition, the stakeholders were responsible for the admission process and AD completions. The administrator reviewed critical information about AD education training at the monthly staff meetings. Brochures were provided for all staff members reminding and helping ADVANCE CARE PLANNING 21 them explain to the residents the purpose and benefits of completing their AD (see Appendix D). Sarah Daft's staff followed all other established policies and added the AD policy to their daily practice. Project Timeline The project timeline covered the development of a standardized nurse-driven AD education training supported by evidence. In addition, this timeline outlined project planning, implementation, and evaluation. The table shows the timeline details (see Appendix E). Project Evaluation An AD education training presentation at Sarah Daft ALF in Salt Lake City, Utah, was offered to the staff working that day. Three staff members voluntarily attended the educational presentation and completed a pre- and post-survey. Survey questions assessed the staff member's knowledge and attitudes toward AD completion. After the training and project implementation, the educational presentation supported the culture change, and the importance of AD completion impacted the staff members. Data Maintenance and Security The project survey and results were anonymous, aggregated, and protected in a safe place at Sarah Daft ALF. Access to data was limited to the facility champion, the registered nurse, and the executive director. Others seeking results would need clearance through one of these individuals, protecting the survey results as promised. Data Collection and Analysis Before the education training presentation, paper pre- and post-surveys were distributed to staff members to complete. Survey results were inputted in Microsoft Excel. The pre- and ADVANCE CARE PLANNING 22 post-survey questions were the same (see Appendix B). In addition, the beginning of the survey showed participant demographics (see Table 1). The staff member's knowledge and attitude about AD completion and effectiveness were assessed through the surveys. Staff members were also asked to rate communication among the team at Sarah Daft ALF, the patients, and the family involved. The survey results showed staff members’ perceptions of effective goals of care conversations, communication of sensitive information, patient and family's understanding, and involvement of the patient and family with end-of-life decision-making (see Appendices B and F). In addition, chart checks were completed at one-month intervals and reviewed every quarter in the future. The chart checks performed at monthly intervals showed that completion rates of ADs increased and helped staff members' perception of the importance of ensuring these ADs are completed on time and on each patient. Table 1 Participant Demographics Characteristics n % Gender Female 2 66.7 Male 1 33.3 Age 31-45 1 33.3 45-60 1 33.3 61+ 1 33.3 Ethnicity ADVANCE CARE PLANNING 23 White 2 66.7 Latino/Hispanic 1 33.3 Note. n = 3 Findings In general, the survey showed that staff members at Sarah Daft ALF were unfamiliar or uncomfortable with ADs before the educational training presentation and policy implementation. The pre-survey results showed that, on average, they only rated the questions a seven out of 10. The educational training improved the staff member's knowledge and attitudes about the benefits of completing ADs for all residents nearing the EOL. The post-survey results revealed that in only three areas, staff members did not rate any of the questions less than 8 out of 10. The survey showed that addressing conflicts in care goals needs to be addressed more in-depth to address patient and family concerns (see Appendix F). Moreover, the chart checks revealed that 90% or 35 of 39 residents at Sarah Daft ALF had completed ADs. Strengths The strength of this project was that it was significantly cost-effective. The project processes have also shown their versatility and ability to adapt to various healthcare settings. The educational presentation helped staff members gain more knowledge about ADs. It also positively affected the staff members' attitudes toward implementing an effective AD policy that provided patients and their families with the care they wished for near the EOL. The registered nurse commented that the staff members' overall morale and attitudes had significantly improved regarding the completion of ADs (J. Beck, personal communication, July 22, 2022). In addition, the administrator commented on how the culture and attitudes have changed since the ADVANCE CARE PLANNING 24 implementation of this project and that there is an overall positive attitude among the staff members towards the importance of completing patients' ADs (Paul Ogilvie, personal communication, July 22, 2022). Weaknesses Two weaknesses were identified in the project implementation. First, not all staff members were required to attend the training presentation. Second, no training presentations were scheduled for new hires. Third, the small number of staff members who participated in the educational training presentation was also a project weakness. Quality Improvement Discussion This quality improvement project aims to provide ACP training by creating a standardized policy and a nurse-driven education protocol to help train staff members at Sarah Daft ALF. Proper training and education of the staff members prepare them to educate the patients and families about the importance of ACP. This project shows that education has helped staff members gain more knowledge about ADs and significantly increased the morale and attitudes of the staff members. Other project components include being cost-effective, versatile, and adaptable to various healthcare settings. Most importantly, it positively impacted the staff's culture towards the importance of completing patients' ADs. The project results have been shared with the team at Sarah Daft. In addition, project dissemination was shared with peers and the WSU Annie Taylor Dee School of Nursing faculty and is available at the WSU Stewart Library DNP Repository. Translation of Evidence into Practice An organization's standardization of ACP training, a universal policy, and a nurse-driven education protocol shows that EOL discussions improved and became easier after repeated ADVANCE CARE PLANNING 25 exposure (Rhodes et al., 2015). In addition, implementing a standardized policy and training increases understanding of ADs and motivates staff members to ensure patients have completed them. Most importantly, the standardization of this policy and education training reveals that 90% of the residents had completed ADs in their charts after chart checks were completed. New knowledge gained about the barriers of this project includes that not all staff members were required to attend the education training and that there was no additional training scheduled for new staff hires. Another project weakness is the small number of staff members at the education training. However, with timely chart checks at one-month intervals, the implementation shows that completion rates of ADs increased and helped staff members' attitude change regarding how essential it is to ensure ADs are completed on each patient. Implications for Practice and Future Scholarship The project findings demonstrate that standardization of policy and nurse-drive education and follow-up can improve the staff's knowledge and attitudes about the overall benefits of completing ADs for all residents at Sarah Daft ALF who are nearing the EOL. In addition, requiring all staff members to attend the training and scheduling new hire training can enhance the number of completed ADs and change most staff members' knowledge and attitudes about ADs. Suggestions for the future scholarship include providing effective education in an ALF where staff attendance has restrictions related to scheduling conflicts and how to hold the current facility champion and future facility champions accountable when facing new admits or changes to the current policy. Sustainability The cost of this project's development and implementation is minimal. The policy is in place, and the facility champion at Sarah Daft ALF has integrated the education training. Staff ADVANCE CARE PLANNING 26 education is assigned to the facility champion with oversight by Paul Ogilvie, the facility administrator. The sustainability of this project includes ensuring the current policy is updated when evidence-based changes are made. Dissemination This project and its outcomes are shared with the project team. In addition, the nurse-driven education and training are disseminated to the administrator, Paul Ogilvie, and other leaders at Rocky Mountain Care as needed. Because the AD policy is completed and working at Sarah Daft ALF, it can be easy to share with other ALFs within the Rocky Mountain Care continuum. Project dissemination includes presenting project implementation and results to peers and faculty during a poster presentation at the Annie Taylor Dee Son of Nursing in Fall 2022. In addition, the project paper is available at the WSU Stewart Library DNP Repository for public access. Conclusion The lack of an AD policy and incomplete ADs at Sarah Daft ALF led to the standardization of an AD policy and nurse-driven education, increasing the number of completed ADs in the facility. By implementing this project, staff members reported an increased knowledge level. They felt more comfortable about what advance directives are, the importance of completing advance directives, and competency with end-of-life discussions. Also, post-training surveys indicated that more than 90% of staff members support the advance directives policy and that 90% of the patients at Sarah Daft ALF have completed ADs. Finally, EOL conversations created a greater understanding between the patient and their loved ones or proxy caregiver (Ditto et al., 2021). ADVANCE CARE PLANNING 27 References Ampe, S., Sevenants, A., Smets, T., Declercq, A., & Audenhove C. V. (2017). Advance care planning for nursing home residents with dementia: Influence of 'we 'decide' on policy and practice. Patient Education and Counseling, 100(1), 139-146. https://doi.org/10.1016/j.pec.2016.08.010 Bazargan, M., Cobb, S., & Assari, S. (2021). Completion of advance directives among African Americans and Whites adults. Patient Education and Counseling, 2021. https://doi.org/10.1016/j.pec.2021.03.031 Benson, W. F., & Aldrich, N. (2012). Advance care planning: Ensuring your wishes are known and honored if you are unable to speak for yourself. 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Overview of systematic reviews of advance care planning: Summary of evidence and global lessons. Journal of Pain and Symptom Management, 56(3), 436-459. https://doi.org/10.1016/j.jpainsymman.2018.05.016 Leaving Well Utah. (2019). Advance directives. https://leaving-well.org/make-wishes-clear/advance-directives Levy, M., Curtis, J. R., Luce, J., Nelson, J., & Clarke, E. (n.d.). Measuring the quality of palliative care in the intensive care unit. UW School of Medicine. http://depts.washington.edu/eolcare/pubs/wp-content/uploads/2011/09/pallcareQA-rnvers.pdf ADVANCE CARE PLANNING 30 Lopez, R. P., Mitchell, S. L., & Givens, J. L. (2017). Preventing burdensome transitions of nursing home residents with advanced dementia: 'It's more than advance directives. Journal of Palliative Medicine, 20(11), 1205-1209. https://doi.org10.1089/jpm.2017.0050 McClay, R., Natividad, J., & Mileski, M. (2021). Changes to a shift reporting sheet on a critical care unit—Nurse perceptions and lessons learned. Journal of Multidisciplinary Healthcare, 14, 381-387. https://doi.org/10.2147/JMDH.S289384 Miller, H., Tan, J., Clayton, J. M., Meller, A., Hermiz, O., Zwar, N., & Rhee, J. (2019). Patient experiences of nurse-facilitated advance care planning in general practice setting: A qualitative study. BioMed Central Palliative Care, 18(25), 1-8. https://doi.org/10.1186/s12904-019-0411-z Mroz, E., Bluck, S., & Smith, K. (2020). Young 'adults' perspectives on advance care planning: Evaluating the death over dinner initiative. Death Studies, 1-10. https://doi.org/10.1080/07481187.2020.1731015 National Institute on Aging. (2018). Advance care planning: Health care directives. https://www.nia.nih.gov/health/advance-care-planning-health-care-directives Portanova, J., Ailshire, J., Perez, C., Rahman, A., & Enguidanos, S. (2017). Ethnic differences in advance directive completion and care preferences: What has changed in a decade? Journal of the American Geriatrics Society, 65(6), 1352-1357. https://dx.doi.org/10.1111%2Fjgs.14800 Ramsbottom, K., & Kelley, M. L. (2014). Developing strategies to improve advance care planning in long term care homes: Giving voice to residents and their family members. International Journal of Palliative Care, 2014. https://doi.org/10.1155/2014/358457 ADVANCE CARE PLANNING 31 Rao, J. K., Anderson, L. A., Lin, F. C., & Laux, J. P. (2014). Completion of advance directives among U.S. consumers. American Journal of Preventive Medicine, 46(1), 65-70. https://doi.org/10.1016/j.amepre.2013.09.008 Reinhardt, J. P., Chichin, E., Posner, L., & Kassabian, S. (2014). Vital conversations with family in the nursing home: Preparation for end-stage dementia care. Journal of Social Work in End-Of-Life & Palliative Care, 10(2), 112-126. https://doi.org/10.1080/15524256.2014.906371 Rhodes, R. L., Tindall, K., Xuan, L., Paulk, M. E., & Halm, E. A. (2015). Communication about advance directives and end-of-life care options among internal medicine residents. American Journal of Hospice & Palliative Medicine, 32(3), 262-268. https://doi.org/10.1177/1049909113517163 Siden, E. G., Carter, R. Z., Barwich, D., & Hassan, E. (2021). Part of the solution: A survey of community organisation perspectives on barriers and facilitating actions to advance care planning in British Columbia, Canada. Health Expectations, 1. https://onlinelibrary.wiley.com/doi/full/10.1111/hex.13390 Stewart, F., Goddard, C., Schiff, R., & Hall, S., (2011). Advanced care planning in care homes for older people: A qualitative study of the views of care staff and families. Oxford Academic, 40(3), 330-335. https://doi.org/10.1093/ageing/afr006 Sudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Matlock, D. D., Rietjen, J. A. C., Korfage, I. J., Ritchie, C. S., Kutner, J. S., Teno, J. M., Thomas, J., McMahan, R. D., & Heyland, D. K. (2017). Defining advance care planning for adults: A consensus definition from a multidisciplinary Delphi panel. Journal of Pain and Symptom Management, 53(5), 821-832. https://doi.org/10.1016/j.jpainsymman.2016.12.331 ADVANCE CARE PLANNING 32 Trarieux-Signol, S., Bordessoule, D., Ceccaldi, J., Malak, S., Polomeni, A., Fargeas, J. B., Signol, N., Pauliat, H., & Moreau, S. (2018). Advance directives from hematology departments: The 'patient's freedom of choice and communication with families. A qualitative analysis of 35 written documents. BioMed Central Palliative Care, 17(10), 1-12. https://doi.org/10.1186/s12904-017-0265-1 Vermunt, N. P. C. A., Harmsen, M., Westert, G. P., Olde Rikkert, M. G. M., & Faber, M. J., (2017). Collaborative goal setting with elderly patients with chronic disease or multimorbidity: A systematic review. BioMed Central Geriatrics, 17(167), 1-12. https://doi.org/10.1186/s12877-017-0534-0 Verreault, R., Arcand, M., Misson, L., Durand, P., Kroger, E., Aubin, M., Savoie, M., Hadjistavropoulos, T., Kaasalainen, Bedard, A., Gregoire, A., & Carmichael, P. H. (2018). Quasi-experimental evaluation of a multifaceted intervention to improve quality of end-of-life care and quality of dying for patients with advanced dementia in long-term care institutions. Palliative Medicine, 32(3), 613-621. https://doi.org/10.1177/0269216317719588 Vries, K. D., Banister, E., Dening, K. H. & Ochieng, B. (2019). Advance care planning for older people: The influence of ethnicity, religiosity, spirituality and health literacy. Nursing Ethics, 26(7-8), 1946-1954. https://doi.org/10.1177/0969733019833130 Wickersham, E., Gowin, M., Deen, M. H., & Nagykaldi, Z. (2019). Improving the adoption of advance directives in primary care practices. Journal of the American Board of Family Medicine, 32(2), 168-179. https://doi.org/10.3122/jabfm.2019.02.180236 Zwakman, M., Jabbarian, L, Delden, J. V., Heide, A. V. D., Korfage, I., Pollock, K., Rietjens, J., Seymour, J., & Kars, M. C. (2018). Advance care planning: A systematic review about ADVANCE CARE PLANNING 33 experiences of patients with a life-threatening or life-limiting illness. Palliative Medicine, 32(8), 1305-1321. https://doi.org/10.1177/0269216318784474 ADVANCE CARE PLANNING 34 Appendix A Advance Directive Policy Rocky Mountain Care Policies & Procedures Manual POLICY #: 2005 SUBJECT: Advance Directives Effective Date: 5/22/98 Revised: 11/28/2016 PURPOSE: A resident's choice about advance directives will be respected. PROCEDURE: 1. Prior to, or upon admission, a representative of the social services department or designee will provide residents with written information concerning the resident's right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare an advance directive. 2. Prior to or upon admission, ask the resident and/or his/her family members about the existence of any advance directives prepared by the resident. Necessary physician orders will be obtained and included in the resident’s medical record for all DNR (do not resuscitate) residents. 3. If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual’s resident representative in accordance with state law. a. The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. 1. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. 4. Should the resident indicate that he or she has issued advance directives about his or her care and treatment, the facility will make an effort to obtain a copy of such directives to be included in the medical record. 5. Until a complete advance directive is in the resident’s medical record all emergency measures will be taken to resuscitate the resident. 6. Advance directives are defined as preferences regarding treatment options which may include, but are not limited to: ADVANCE CARE PLANNING 35 a. Living Will -- A document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis certified in writing by two (2) physicians who have personally examined the resident. b. Do Not Resuscitate -- Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) have directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. c. Do Not Hospitalize -- Indicates that the resident is not to be hospitalized, even if he or she has a medical condition that would usually require hospitalization. d. Organ Donation -- Indicates that the resident wishes his or her organs to be available for transplantation upon his or her death. e. Autopsy Request -- Indicates that the resident, legal guardian, healthcare proxy, or representative (sponsor) has requested an autopsy be performed upon the death of the resident. (Note: The family member or legal guardian making the request must still be contacted for permission prior to performance of the procedure.) f. Feeding Restrictions -- Indicates that the resident, legal guardian, health care proxy, or representative (sponsor) does not wish for the resident to be fed by artificial means (e.g., tube; intravenous nutrition, etc.) if he or she is not able to be nourished by oral means. g. Medication Restrictions -- Indicates that the resident, legal guardian, health care proxy, or representative (sponsor) does not wish for the resident to receive life-sustaining medications (e.g., antibiotics, chemotherapy, etc.). h. Other Treatment Restrictions -- Indicates that the resident, legal guardian, healthcare proxy, or representative (sponsor) does not wish for the resident to receive certain medical treatments. Examples include, but are not restricted to, blood transfusions, tracheotomy, respiratory intubation, etc. 7. In accordance with the Utah State Law, a resident who is unable to communicate his wishes (and has no legal guardian, spouse, parent, or children over 18 who can act on the resident’s behalf) will be resuscitated. If this condition exists and the person is terminally ill, life-sustain procedures will be implemented in accordance with Utah Code 75-2-1107, (UCA). In accordance with Wyoming state law, a (a) If a valid advance health care directive does not exist, a surrogate may make a health care decision for a patient who is an adult or emancipated minor if the patient has been determined by the primary physician or the primary health care provider to lack capacity and no agent or guardian has been appointed or the agent or guardian is not reasonably available. (WY Stat § 35-22-406 (2013)). 8. Utah: If the resident has completed a Special Power of Attorney, it will become effective only when the physician certifies that the resident has incurred a physical or mental condition rendering him unable to give current directions to attending physicians or other providers of medical services as to his care and treatment. (Utah Code Section 75-2-1105, UCA). Wyoming: Unless otherwise specified in a power of attorney for health care, the authority of an agent becomes effective only upon a determination that the principal lacks capacity, and ceases to be effective upon a determination that the principal has recovered capacity. WY Stat § 35http://law.justia.com/citations.html22-403 (2013) ADVANCE CARE PLANNING 36 9. Utah: If advance directive documents were developed in another state, the resident must have such documents reviewed and revised by legal counsel in this state before the facility may honor such directives. Wyoming: POLST forms from another State shall be presumed valid unless notice of revocation or termination of form is present. Wyoming 35-22-501 10. The care plan team (IDT) will review quarterly with the resident his or her advance directives to ensure that they are still the wishes of the resident. Such reviews will be made and recorded on the resident assessment instrument (MDS). 11. Changes to or revocations of an advance directive must be submitted in writing to the facility. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. Copies of changes to an advance directive must be filed in the resident's medical record located at the nurses' station. 12. The attending physician will be responsible for issuing appropriate orders that coincide with the resident's advance directive. The physician's orders must be documented in the resident's medical record and plan of care. 13. The facility will not condition the provision of care or otherwise discriminate against a resident, based on whether or not the individual has executed an advance directive. 14. Advance directive in-service training programs for both the staff and community are provided annually. 15. The facility will inform the resident prior to or upon admission of any limitations that it has (based on conscience) on the implementation of a resident's advance directive. Such policy will include -- a. Any differences between the facility's conscience objections and those of the attending physician; b. The state legal authority citations that permit such objections; and c. A listing of the medical conditions or procedures affected by the conscience objection. 16. Inquiries concerning advance directives should be referred to the admission coordinator, social services, or director of nursing. Review Dates and Initials 42 CFR References 483.10(b)(4)&(8); 483.20(d)(1); 483.20(d)(2)(i)&(ii); 483.25; 483.75(b); 489.100-489.104 Survey Tag #s F155; F156; F279; F280; F309; F492 MDS Version 2.0 Section A10 ADVANCE CARE PLANNING 37 Appendix B Pre-Post Survey Sarah Daft Assisted Living Quality Assessment Tool Bedside Nurse Survey Spencer Noyce, MSN, DNP Student, RN Weber State University School of Nursing 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 Spencer Noyce at spencernoyce@mail.weber.edu. Demographic Information: 1. What gender do you identify as? A. Male B. Female C. ________ (Short Answer Space) D. Prefer not to answer. 2. What is your age? A. 0 - 15 years old B. 16 - 30 years old C. 31 - 45 years old D. 46-60 years old E. 61+ E. Prefer not to answer 3. Please specify your ethnicity A. Caucasian B. African American C. Latino or Hispanic D. Asian E. Native American F. Native Hawaiian or Pacific Islander G. Two or More H. Other/Unknown I. Prefer not to say Pre-Survey Assessment: ADVANCE CARE PLANNING 38 Communication Within the Team and with Patients and Families For questions 4-7, indicate How often at Sarah Daft do... 4. Doctors meet with nurses to clarify goals of patient care? Never 0 1 2 3 4 5 6 7 8 9 10 Always 5. Attending physicians meet at least once with the patient’s family? Never 0 1 2 3 4 5 6 7 8 9 10 Always 6. Physicians, when meeting with families, meet with them in a private conference room? Never 0 1 2 3 4 5 6 7 8 9 10 Always 7. Clinicians identify a family member who will serve as the contact person for the family? Never 0 1 2 3 4 5 6 7 8 9 10 Always For questions 8-11, circle the number that best reflects How well do staff at Sarah Daft... 8. Address conflicts about goals of care within the clinical team prior to meeting with the patient and/or family? Worst Possible 0 1 2 3 4 5 6 7 8 9 10 Best possible 9. Communicate distressing news to the patient and/or family in a sensitive way? Worst possible 0 1 2 3 4 5 6 7 8 9 10 Best possible 10. Ensure that the patient and/or family understand the patient’s condition? Worst possible 0 1 2 3 4 5 6 7 8 9 10 Best possible 11. Prepare the patient and/or family for the dying process? Worst possible 0 1 2 3 4 5 6 7 8 9 10 Best possible Patient and Family Centered Decision-Making For questions 12-16, indicate How often do staff at Sarah Daft... 12. Consider the family as well as the patient as the focus of care? Never 0 1 2 3 4 5 6 7 8 9 10 Always ADVANCE CARE PLANNING 39 13. Determine whether the patient has an advance directive? Never 0 1 2 3 4 5 6 7 8 9 10 Always 14. Place the patient’s advance directive in the chart? Never 0 1 2 3 4 5 6 7 8 9 10 Always 15. Assess the treatment preferences of the patient who has decision-making ability? Never 0 1 2 3 4 5 6 7 8 9 10 Always 16. Identify the patient’s health care proxy or other surrogate decision-maker? Never 0 1 2 3 4 5 6 7 8 9 10 Always 17. How confident do you feel about implementing the new advance directive policy? Worst possible 0 1 2 3 4 5 6 7 8 9 10 Best possible 18. If you do not feel confident about implementing the new advance directive policy, what can we do to support you? The post-survey provided are the same questions and includes the demographic section Questions 4-16 adapted from the following: Levy, M., Curtis, J. R., Luce, J., Nelson, J., & Clarke, E. (n.d.). Measuring the quality of palliative care in the intensive care unit. UW School of Medicine. http://depts.washington.edu/eolcare/pubs/wp-content/uploads/2011/09/pallcareQA-rnvers.pdf ADVANCE CARE PLANNING 40 Appendix C PowerPoint Presentation ADVANCE CARE PLANNING 41 ADVANCE CARE PLANNING 42 ADVANCE CARE PLANNING 43 ADVANCE CARE PLANNING 44 ADVANCE CARE PLANNING 45 ADVANCE CARE PLANNING 46 ADVANCE CARE PLANNING 47 ADVANCE CARE PLANNING 48 ADVANCE CARE PLANNING 49 Appendix D Brochure 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. ADVANCE CARE PLANNING 50 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 ADVANCE CARE PLANNING 51 Appendix E Timeline Summer 2021 • Gather literature related to advanced directive policy education programs and resources- June 2021. • Meet with department heads and clinical staff to discuss current policy and design future policy and implementation model- June 2021. • Identify a team champion to establish a sustainable advance directive policy implementation- July 2021. • Approve project proposal 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. • If ready, begin project implementation. Spring 2022 • Begin project implementation March 4, 2022. • Interval chart audits April, May, and June. Summer 2022 • Complete project implementation June 2022. • If ready, begin project evaluation. ADVANCE CARE PLANNING 52 Fall 2022 • Complete project evaluation. • Complete project dissemination. ADVANCE CARE PLANNING 53 Appendix F Sarah Daft Assisted Living Quality Assessment Tool Bedside Nurse Survey Results Table 2 Sarah Daft Assisted Living Quality Assessment Tool Bedside Nurse Survey Results Questions Staff 1 Staff 2 Staff 3 4. Doctors/nurses clarify goals 4 (8) 8 (10) 4 (9) 5. Doctor meets with family 6 (8) 9 (10) 5 (9) 6. Doctor meet with family in private 8 (10) 10 (10) 6 (9) 7. Doctor identifies family contact 7 (9) 10 (10) 7 (9) 8. Staff addresses conflict on goals of care 6 (8) 7 (9) 7 (9) 9. Staff presents distressing news professionally 9 (10) 7 (10) 7 (9) 10. Staff explains patient condition clearly 8 (10) 6 (10) 7 (9) 11. Staff prepares patient and family for dying 6 (9) 7 (10) 8 (10) 12. Family and patient are focus of care 7 (9) 7 (10) 8 (9) ADVANCE CARE PLANNING 54 Questions Staff 1 Staff 2 Staff 13. Staff determines if advance directive is completed 5 (9) 7 (10) 8 (10) 14. Place advance directive in chart 7 (10) 7 (10) 6 (9) 15. Know treatment preferences of decision maker 7 (10) 7 (10) 6 (9) 16. Identify decision maker 7 (10) 7 (9) 6 (9) 17. How confident staff is in implementing new advance directive policy 5 (9) 7 (10) 8 (10) Note: The scale used for each question: Never 0 1 2 3 4 5 6 7 8 9 10 Always. Pre-survey (numbers without parentheses) given prior to advance directive presentation, and post survey given two months after implementation (number with parentheses).