Annals of Long Term Care

Introduction
A majority of residents in long-term care (LTC) are at risk for frequent hospitalizations, functional decline, and death.^1,2 Transitions from the hospital, with declines in functional status, with new life-threatening diagnoses, are common in LTC. These transitional events are opportunities to review resident/family understanding and update goals of care. Ideally, conversations about advance care planning occur prior to admission to a LTC community; however, this is not always the case. Even if an advance care planning document exists, it should be reviewed. Advance care planning discussions are a genuine opportunity to elicit residents’ goals and preferences about their healthcare. This type of planning is essential to high-quality care in the LTC setting.

In LTC, clinicians can use significant transition points (ie, admission/readmission, significant changes, transfer) for advance care plan discussions. In the LTC setting, the multidisciplinary team assigned to each resident is responsible for initiating and following through with the advance care planning process. The care team may include a nurse, social worker, dietician, physical therapist, recreational therapist, chaplain, personal care aide, administrator, and physician. This team is often charged with eliciting preferences in the LTC setting when no previous advance care planning document exists. One approach could be to incorporate these questions into the initial care planning process at the time of admission by utilizing a family meeting. Whenever the resident’s care plan is reviewed or modified, it is also necessary to ensure that the resident’s (and family’s) goals of care are updated.

Unique Challenges
The challenges faced in LTC include a high prevalence of cognitive impairment, unclear decision-making status, distant families, unclear or conflicting documentation, and conflicts within the care team. Over half of all nursing home residents have some degree of cognitive impairment, but a little less than half have the diagnosis of dementia in their record.³Family members of LTC residents often are needed to help discern a resident’s values and preferences to act as surrogate decision makers. Unfortunately, many may live far away, thus limiting their contact with their loved one, as well as limiting their full understanding of the resident’s clinical picture. Communication with families may sometimes be over the phone and not in person. This makes it much more difficult to perceive nonverbal cues and risks misinterpretation of language. There may also be an underestimation or lack of understanding of the effect of any underlying family conflict.

Other LTC residents may not have any living relatives, which presents a legal problem of finding a healthcare power of attorney if the patient has lost decision-making capacity. (This discussion is beyond the scope of this article.) Staff involvement may add another layer of complexity to the communication when a resident in the LTC community has staff members who feel like “family.” This attachment can cause decisions for end-of-life care to be difficult for the multidisciplinary team to follow. In addition, the medical record may be too complex to navigate and/or the advance care planning form too limited (or too cumbersome), making it arduous for clinicians or other members of the LTC team to complete.

Approaches of Advance Care Planning Discussions
To abide by a resident’s wishes and provide a plan of care that is congruent with his/her goals of care, advance care planning conversations are crucial.