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Editor’s note: This is the third article in a multipart series about advance care planning and how to operationalize an effective program in nursing homes. Find the first article explaining the basics of what it is and why it matters here and the second article explaining how to use advance care planning for maximum effectiveness in providing person-centered care here.
Advance care planning involves more than completing documents, such as advance directives and POLST (Physician Orders for Life-Sustaining Treatment) forms, says Shigeko (Seiko) Izumi, PhD, RN, FPCN, associate professor in the School of Nursing at Oregon Health & Science University in Portland, OR; presenter of the April 22 webinar “COVID Conversations: Team Approach To Assisting Patients With Advance Care Planning” from the Coalition for Compassionate Care of California; and co-author of “A Model to Promote Clinicians' Understanding of the Continuum of Advance Care Planning” in the Journal of Palliative Medicine (2017; 20(3):220-22).
“It’s a mistake to fixate on the paper documents. Without conversation, the documents alone don’t help much because they can be overlooked in times of crisis,” stresses Izumi. “The most important part of advance care planning is having the conversation to learn the resident’s values, goals, and treatment preferences—and making sure the people around that resident also know what is important to them so that even without documentation, they can advocate for the resident when the resident cannot express their own wishes.”
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