Introducing Advance Care Planning into Nursing Homes & Hostels

1) Although it may be important to have Advance Care Directives in admission packs, many prospective residents
and families have a lot on their minds around the time of admission. So a resident should always be
approached about a month after admission about their wishes for treatment if they lose capacity and the
concept of ACDs. If they are interested they should be asked to involve the relevant ‘person responsible’ and a
time can be made to introduce the ACD to them together. They can either fill it out with nursing staff or in their
own time. Excluding families from this process is likely to alienate them from the process and make it difficult
to advocate for the decisions made in the ACD if the situation ever arises.

2) Manage processes for standardised recording and filing of ACDs. Protocols to transfer ACDs with every hospital
admission. Listing ACD as one of the documents for admission envelope.

3) The families or ‘person responsible’ for patients with severe dementia or vegetative states who can no longer
make decisions for themselves should be given written information on Substitute Decision Making, a short
information sheet is available on this site. Written information has the advantage of being standardised and
can be reviewed at the families’ leisure. The Information Sheet can also be passed around many family
members who may not have attended any Nursing Home discussion.

4) ‘Person’s responsible’ who express the desire that they would like only palliative care for their family member
should be given a Palliative Care Wishes form ...... available on this website.

5) Nurse and GP Training:

a. In delivery and use of Advance Care Directives: “attuning patients to issues”
see 8 minute video on ACDs on this website
b. In Advance Care Planning and informed substitute decision making for those
patients who lack capacity to decide.
c. Concepts of informed choice, advocacy of patient rights and views of the
elderly when they complete ACDs.
d. Understanding risks and ‘benefits’ of refusing consent to treatment.
e. Training for all or specific ACP interested nurses

6) Nurse & Doctor Medication Reviews, in particular life prolonging drugs:

a. Blood thinners: Aspirin/Plavix/Iscover/Warfarin
b. Anti-hypertensives
c. Cholesterol medications: Statins/Lipitor/Zocor/Pravachol
d. Concept of pharmaceutical life support: is this what the patient or family
wants?
e. At least annual review or when major change in patient condition.

7) Nurse Review of informed consent for:

a. Vaccinations (Flu & Pneumonia)
b. Nutritional Supplements
c. Hospital transfer
d. Review of processes and care plans to deal with these
8) Encouraging informed choice and advance care planning by involving GP with families:
a. To discuss ACP, medications, vaccines, supplements and hospital transfer
b. Comprehensive Medical Assessments (Item 712).
c. Review of Care Plans (Item 731), Case Conferencing (Item 734+736
d. Appointments at GP surgeries with patient notes and medication charts