Advance Care Planning

For Healthcare Professionals

Background to the Advance Care Planning: Goals of Care Designation (Adult) Policy

Background:

On November 25, 2008, the Calgary Area of Alberta Health Services implemented an "Advance Care Planning: Goals of Care Designation (Adult)" policy. A Pediatric version of this policy was implemented on September 29, 2009.

This policy represents leading edge work in Canada and responds to the shifting needs and demands in healthcare. The epidemiology of dying is changing due to our aging population and the concomitant burden of chronic diseases and invasive cancer. At least 2/3 of us will die with one or more serious chronic illnesses that will gradually restrict our activities and lead to serious exacerbations requiring hospitalization. Furthermore, medical advancements are making health care decisions increasingly complex due to the varying degrees of benefits and burdens for the patient, and the family.

However, the current context in health regarding advance care planning and goals of care (often referred to as Code Levels or DNR Orders) did not reflect this changing reality of health care. Rather, they reflected the following:

the focus was on whether or not "resuscitation" interventions would be offered with minimal discussion on the many other more common decisions that need to be made during the course of a patients chronic illness (how aggressively to treat underlying disease, whether to transfer the patient to higher level of care, etc).
Levels of Care / DNR orders were defined differently in the different sites in the care continuum.
there was no established decision-making process.
there was no consistent documentation of decisions and access to documentation regarding decisions was unreliable, particularly at points of transition.

In response to the quality of care and patient safety issues that existed due to the deficiencies noted above, a comprehensive regional policy titled "Advance Care Planning: Goals of Care Designation (Adult) policy was developed. Extensive stakeholder consultation within the Calgary Health Region and with our key partners occurred throughout all steps of the policy development and implementation.

Policy Features

The policy introduces three key innovative changes to health care service philosophy and delivery

a decision making framework that is focused on the broader goals of care rather than just the act of resuscitation,
portability of the framework across all care settings, and
the integration of advance care planning philosophy and principles into decision making processes.

Specifically, it includes the following:

A mandate for heath care clinicians to consistently address goals of care which include a focus on potential benefits and burdens of CPR and other investigations for people living with advanced medical illnesses. A regional Goals of Care Designation framework systematically codifies goals of care and provides direction for all care providers.
A process that supports inter-professional practice and ensures that when clinically relevant, individuals have a Goals of Care Designation (GCD) Order in place that is based on conversation between the health care team and individual. These GCD Orders are written by the Most Responsible Health Care Provider (usually Physician) and are transportable as an individual moves through the continuum of care.
A framework for engaging in goals of care conversations that address medically appropriate treatments in light of an individual's goals, values and beliefs. It supports documentation of an individual's wishes in order to provide crucial information that informs immediate health care decisions as well as future situations where an individual may not be able to speak for themselves. This process integrates advance care planning philosophy and practice.
An Advance Care Planning Tracking Record (chart form) that captures key outcomes related to goals of care conversations and decisions. This form also travels with an individual in order to inform new or receiving health care teams regarding previous discussions and decisions related to goals of care.
Quick Reference posters and pocket cards for clinicians.
Defined Decision Support resources and a Dispute Resolution process.
Alignment with the revised provincial Personal Directives Act which was proclaimed in spring 2008.

The policy work is supported by a suite of "My Voice - Planning Ahead" resources developed to engage individuals, their families and health care providers in advance care planning activities. Resources include a DVD introduction to advance care planning, brochures and a "My Voice" workbook that guides an individual through a reflective process and documentation related to future health care decision-making. Specific work with chronic disease pilot groups and extensive feedback from participants and a Community Task group informed the development of these tools.

Outcomes

Implementation of this policy is expected to have a significant impact on reducing the current patient safety risks that are related to the lack of a universal policy and goals of care designation system across the care continuum. Furthermore, the investment in conversations with the patient and the family regarding their values and goals and how those intersect with what is determined to be medically appropriate treatment, will reduce the frequency with which situation regarding end of life decisions result in conflict. The new policy will also mitigate the moral distress experienced by staff when patients are in crisis and the goals of care are unknown.

An evaluation plan is in place to measure the following key outcomes

Outcome	Indicators and data sources
The Advance Care Planning: Goals of Care Designation (Adult) policy is being fully implemented across the Calgary Zone of AHS	Evidence of GCD Order, ACP Tracking Record, advance directive and goals of care discussions on health record Data sources: Regional chart audits (pre-implementation/ baseline, 3 & 12 months post implementation) and electronic health records
Patients’ preferences as identified in their advance directives are followed as they receive medically appropriate end of life care	Chart audit
Information related to future health care decisions transfers with patients across service streams	Data sources: Regional chart audits (pre-implementation/ baseline, 3 & 12 months post implementation) and electronic health records.
Health care providers find the Advance Care Planning: Goals of Care Designation (Adult) policy, documentation and processes useful and beneficial	Data sources: Post-implementation surveys, chart audits and focus groups
Clinicians receive fundamental policy education:	75% (13,212) staff completed a policy online learning module (Dec. 24/08) 42% (1227) physicians completed a policy online learning module (Dec. 24/08)
Clinicians achieve learning objectives:	82% (3161/ 3870) reported that the online module was useful and will have practical application for work 75% (2912/ 3860) reported that participating in the online module is likely to improve outcomes for patients
Patients (and families) find goals of care planning discussions beneficial	Data sources: Surveys

Next steps and opportunities

Within Alberta Health Services - Calgary Area, the Policy Implementation team will continue to support this work by engaging change management principles and quality improvement activities to ensure this work continues to be integrated into clinical practices and regional systems. Following completion of the evaluation and related changes, opportunities to implement the policy throughout AHS will be explored.