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Advance Care Planning

Advance care planning (ACP) is a critical component of care in post-acute and long-term care (PALTC) settings. It represents a proactive approach to patient care, fostering dialogue about future health care choices among patients, families, and healthcare providers. As the trajectory of illnesses shift and end-of-life nears, having a plan grounded in patients’ values, goals, and preferences is essential.

In the older adult population, chronic illnesses and the potential for cognitive decline necessitate early and recurrent discussions about the patients' wishes. This involves not only end-of-life decisions but also preferences regarding interventions, hospitalizations, and potential scenarios of declining health.

The first step in the advance care planning process is initiating the conversation, which should be framed around the patient's values, beliefs, and understanding of their health. The goal is to ensure that the patient’s wishes are understood and respected.

Once the dialogue begins, several key components should be addressed:

  • Health Care Proxy: Identifying an individual who can make decisions on behalf of the patient if they are incapacitated. This person should be familiar with the patient's values and beliefs and be willing to act on their behalf.
  • Living Will: This is a written statement detailing a person's desires regarding future medical treatments in circumstances where they are no longer able to express informed consent.
  • DNR and DNI orders: Discussing resuscitation and intubation preferences and ensuring clear documentation.
  • Goals of Care: Conversations around potential future scenarios – hospitalizations, aggressive treatments, comfort care preferences, and more. This may evolve as the patient's health changes.
  • Review and Revisit: ACP isn’t a one-time conversation. As health status changes, or as patients move between care settings, revisiting the plan is essential.
  • Cultural and Spiritual Considerations: Ensuring that care planning respects patients’ cultural, spiritual, and personal beliefs. 

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