Advance care planning for residents in aged care facilities: what is best practice and how can evidence-based guidelines be implemented?

Abstract

Background Advance care planning in a residential care setting aims to assist residents to make decisions about future healthcare and to improve end-of-life care through medical and care staff knowing and respecting the wishes of the resident. The process enables individuals and others who are important to them, to reflect on what is important to the resident including their beliefs/values and preferences about care when they are dying. This paper describes a project conducted as part of the Joanna Briggs Institute Clinical Aged Care Fellowship Program implemented at the Manningham Centre in metropolitan Melbourne in a unit providing services for 46 low and high care residents. Objectives The objectives of the study were to document implementation of best practice in advance care planning in a residential aged care facility using a cycle of audit, feedback and re-audit cycle audit with a clinical audit software program, the Practical Application of Clinical Evidence System. The evidence-based guidelines found in 'Guidelines for a Palliative Approach in Residential Aged Care' were used to inform the process of clinical practice review and to develop a program to implement advance care planning. Results The pre-implementation audit results showed that advance care planning practice was not based on high level evidence as initial compliance with five audit criteria was 0%. The barriers to implementation that became apparent during the feedback stage included the challenge of creating a culture where advance care planning policy, protocols and guidelines could be implemented, and advance care planning discussions held, by adequately prepared health professionals and carers. Opportunities were made to equip the resident to discuss their wishes with family, friends and healthcare staff. Some residents made the decision to take steps to formally document those wishes and/or appoint a Medical Enduring Power of Attorney to act on behalf of the resident when they are unable to communicate wishes. The post-implementation audit showed a clear improvement as compliance ranged from 15-100% for the five audit criteria. Strong leadership by the project team was effective in engaging staff in this quality improvement program. Conclusion The outcomes of the project were extremely positive and demonstrate a genuine improvement in practice. All audit criteria indicate that the Manningham Centre is now positively working towards improved practice based on the best available evidence. It is hoped that as the expertise developed during this project is shared, other areas of gerontological practice will be similarly improved and more facilities caring for the older person will embrace evidence-based practice.

Quality of advance care planning policy and practice in residential aged care facilities in Australia

“…This paper presents the key findings of the pre-implementation evaluation; post-implementation changes to these findings will be reported in a future paper. We hypothesised that although pre-implementation ACP awareness and practice within the project facilities may be higher than previously reported, in line with previous research in this area,4 28 30 33 34 the quality of ACP practices would be highly variable.…”

“…The legislation varies in terminology, intent and associated physician liability 27 28. A number of studies have examined aspects of ACP in Australia, including guidelines for implementing ACP in Australian healthcare settings,1 4 29 30 the roles of different health practitioners in supporting ACP,31–34 and the outcomes of a randomised controlled trial in which elderly patients were allocated to receive usual care or facilitated ACP 6. In the specific context of Australian residential aged care facilities (RACFs), development of advance care plans may or may not be part of the institution's policy, and in those settings where the importance of the ACP process is recognised, the quality of processes and instruments developed has been found to be variable and often questionable 4 28 30 33 34.…”

Palliative care in residential aged care facilities

“…Most successful are programmes where a structured training is received and where policies are consistent across care settings. 34,37,39,40,44 What is evident from this paper is that, despite increased interest in palliative care in the residential aged care setting, there is a dearth of well-conducted, rigorous, intervention studies. While randomised controlled trials are difficult to conduct, robust prospective studies with pre-and post-outcome measures for staff, resident and families are possible and urgently required.…”

“…[41][42][43][44][45] Nair et al 45 surveyed Directors of Care regarding the relative use of formal and informal methods of advanced care planning in 88 residential aged care facilities in the Hunter region of New South Wales. They found low levels of formal methods of advanced care planning; only 0.2% of residents had an advanced directive, 1.1% of residents had no CPR orders documented in their medical records, 5.6% had a formal guardian and 2.8% had an enduring guardian.…”

“…Lyon 44 trialed the RPC programme in a residential aged care facility where 14 staff members received RPC training. This included a total of 16 contact hours with a trained facilitator as well as additional one-to-one assistance with an experienced mentor when holding discussions with residents regarding advance care planning.…”