5-S (Environment)
- Scene – Select location for privacy and comfort sensitive to patient’s needs.
- Setting – Create friendly, engaging, quiet and confidential environment.
- Seating – Make patient, family, staff at ease; seating that is congenial and conducive to interaction.
- Scenario – Long-Term Care (LTC) and other settings.
- Start with open ended question – No interruption for the first two minutes and allow silence between responses.
C-A-R-E (Engagement)
- CONSIDER AND CLARIFY
- Cause: What is the reason for the ACP discussion?
(“It is important to know we are choosing medical treatments in keeping with your wishes; these discussions are routine and necessary for all patients in LTC.”) - Clarify: Simplify medical language in patient’s own words; “ask-tell-ask” to aid understanding.
- Condition: What are the relevant medical diagnoses and treatments?
- Consider: The extent to which today’s statements are consistent with previous statements. Seek goals of care consistent with patient preference.
- Cause: What is the reason for the ACP discussion?
- ASSESS AND ASSUME NOT
- Assess: Patient’s perspective with empathy and unbiased, active listening.
- Assess: What is the patient’s (or proxy’s*) self-described perception of their illness, functional status, clinical trajectory, prognosis, and expectation of treatment options and results?
- Assess: What are the cultural, social, family, religious, or other life values that shape the patient’s response to their situation and their perspective on illness?
- Assess: What are the trust issues, if any, that patient has toward medical care?
- Assess: What is the patient’s preference concerning:
- the balance between longevity, functional status and quality of life?
- the balance between relief of symptoms and maintaining lucidity and awareness?
- Assume Not: Avoid imposing your own opinion on the preferences of the patient.
- REFLECT AND RESPOND
- Reflect: On patient’s preference for treatment in their own words.
- Restate: The patient’s ideas, comments, questions.
- Reflect: Are there impending anniversaries “bucket list items”, unfinished business, unspoken agendas or coercive factors which may be influencing patient preferences?
- Respond: Affirm your desire to develop a medical treatment plan consistent with patient preferences, in the context of the issues identified immediately above, if any.
- Respond: Provide education about prognosis and clinical benefits, or lack thereof, of any proposed medical treatments (e.g., CPR, intubation and tube feeding), unless patient does not wish to receive this information. Seek to be culturally sensitive to your individual patient1,2,3.
- Review: Patient’s perspective with affirmation and options for honoring their wishes. Allow them to respond. Engage in shared deliberation of how to best honor their wishes.
- Review: The applicability, if any, of their current Advance Directives and other medical treatment forms, to their current clinical situation. If the current forms do not reflect their goals and desires, recommend the creation of new forms.
- Respond Back: Educate patient on options that reflect their preferences. Review available Advance Directives, Living Will, DNR, and/or POLST Paradigm forms or documents in their particular State.
- Reflect Back: Ask whether the patient has additional questions or change of perspective. Restate their perspective after education and discussion of options.
- 4. EVALUATE AND EXECUTE
- Evaluate: What are the next steps, in light of the above discussion?
- Enter: Any appropriate order to represent those choices (e.g., DNR, Full Code).
- Execute: If any Advance Directives or medical treatment order documents have been completed by the patient at the ACP meeting, document this in this note and make copies of all previous and new document(s) that are valid for the patient and the medical record.
- Execute: Unless patient does not want it shared send copies to the community primary care physician and local hospital.
