Nurse cares for a elderly patient lying in bed in hospital.

Written by: Michelle Lauckner, RN, CADDCT, CDP, RAC-CT, IP-BC; Quality Improvement Advisor [Great Plains Quality Innovation Network]

This day reminds us of the need to not only support our patients and nursing home residents in the formulating and following of Advance Care Planning (ACP), it also reminds us of the need to make our own wishes known.

Statewide resources, Honoring Choices North Dakota and Advance Care Planning South Dakota offers guidance in getting your own wishes written and how to better have those conversations with loved ones

As we reflect on what we want to be the “final chapter of our own story” (borrowed from our wonderful former colleague, Sally May), let’s also consider how we can provide for the best care to meet the values, goals and preferences of our nursing home residents.

The CMS State Operations Manual requires a facility to have a policy to:

  • Determine on admission whether the resident has an advance directive and, if not, offer an opportunity for the resident to formulate an advance directive; and
  • Identify the primary decision-maker;

Does your staff feel comfortable starting this conversation with individuals and family members that have recently had major changes to their lives, health and plans for the future?

Following are additional requirements within the CMS State Operations Manual:

  • Periodically assess the resident for decision-making capacity and invoke health care agent or representative if the resident is determined not to have decision-making capacity;
  • Define and clarify medical issues and present the information regarding relevant healthcare issues to the resident or his or her representative, as appropriate;
  • Identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions;
  • Identify situations where health care decision-making is needed, such as a significant decline or improvement in the resident’s condition;
  • Establish mechanisms for documenting and communicating the resident’s choices to the interdisciplinary team and to staff responsible for the resident’s care; and
  • Identify the process (as provided by State law) for handling situations in which the facility staff and/or physician do not believe that they can provide care in accordance with the resident’s advance directives or other wishes on the basis of conscience.

Does your facility have a process for assessing decision-making capacity? Do all staff have a clear understanding of resident’s desires for care in the event they are unable to clearly express when health declines? Do all staff understand what declining health means to each individual resident? If they do not intimately know all your residents to the extent above, do all staff, know where to find each resident’s advance plan wishes? Are they willing to follow those wishes? In addition to the resources already mentioned, the following can help ensure you and your staff can answer these questions:

As healthcare professionals who see elderly residents nearing death, we may often think that we have “all the time in the world” to have these conversations and document our wishes, but the current COVID-19  pandemic should help us all recognize that no one knows when their time may come and there is no better time then now to get your preferences known.