Goals of Care

1
Goals of Care

• Purpose Identify types of goals in LTC goals
  that reflect the residents change of condition,
  and goals that result from purposeful
  conversations.

2
Objectives

• Understand the diversity of residents in LTC and
  need to individualize
• Appreciate the need for, and know how to develop
  and change the POC based on the residents
  wishes
• Apply regulatory guidance for EOL in LTC.

3
Individualized Care

• LTC facilities have a wide variety of residents,
  such as
• Physical impairment - Cultural Diversity
• Cognitive impairment - Lifestyle Diversity
• Behavioral symptoms - Residents in the last
• Mental illness in last stages of life
• Mental retardation
• Young residents
• Very old residents

4
Individual Care Plans

• Based on individual residents strengths, needs,
  and problems
• Utilizing an interdisciplinary team of experts
• Form the basis of the Resident Assessment
  Instrument (RAI) required in every
  Medicare/Medicaid certified facility and
• Revised frequently.

5
The art and science of nursing is
portrayed at its best in palliative caregiving.
6
Purposeful Observations and Conversations

• Staff must recognize subtle changes.
• Subtle changes can be difficult and requires
  purposeful observation of each resident, and
• Purposeful conversations with the resident, or
  responsible party.
• Goals of treatment and symptom management change
  in response to purposeful observations and
  conversation.

7
Advance Care Planning

• The more knowledge the interdisciplinary care
  planning team has about the residents value
  system, the more likely it is to establish a care
  plan that meets the residents needs and allows
  for appropriate interventions as symptoms change.

8
Defining Quality of Life

• The Interdisciplinary Team (IDT) should engage
  in purposeful conversations with residents to
  ensure that their values and preferences are
  understood.

9
Ask questions, such as

• As you look into your future, what do you want?
• Have you thought about what you would like the
  last phase of your life to be like?
• What will be most important for you during that
  time?

10
End of life discussions may include

• Cardiopulmonary resuscitation (CPR),
• Artificial nutrition and hydration,
• Hospital transfer,
• Withholding diagnostic tests,
• Treatment of existing diagnosis, such as
• congestive heart failure or osteoporosis.

11
Residents without decision-making ability may
require

• Court appointment of legal guardian if no living
  will, advance directive, or designation of a
  surrogate or
• If current documents do not provide guidance in a
  particular situation.
• Facility may need to consult an attorney for
  advise.

12
Ethical Issues

• Ethical issues related to surrogate decision
  making are addressed in
• Considerations regarding life-prolonging
  Treatment for residents of Long-Term Care
  Facilities
• by
• Midwest Bioethics Center

13
Shaping Care and Setting Goals

• The purpose of advance care planning is to
  allow the resident to help shape the care he or
  she receives during the last stages of life.

14
The IDT will make better decisions if it has
relevant information about

• The residents clinical condition and prognosis,
  and
• Personal beliefs and social views.

15
Ethics Case Consultation

• When situations of conflict arise within the
  IDT, may be between family members or between
  professional staff and family members
• Ethics case consultation for mediation
• Facilities can develop ethics committees
• Long-Term Care Ethics Case Consultation by
  Midwest Bioethics Center in conjunction with the
  Missouri Ombudsman Program.

16
Regulatory Compliance for Advance Directives

• F156
• Related to maintaining written policies and
  procedures regarding advance directives.
  Includes provisions to inform and provide written
  information to all adult residents concerning the
  right to accept or refuse medical or surgical
  treatment and form an advance directive.

17
Regulatory Compliance for Advance Directives,
cont.

• F156, cont.
• This includes a written description of the
  facilitys policies to implement advance
  directives and applicable State law.

18
42 CFR 489.102Hospice Regulation

• Provide written information concerning right to
  formulate advance directive
• Document if a resident has an advance directive
  in the medical record
• Not to discriminate based on whether or not a
  patient has an advance directive
• Ensure compliance with State law regarding
  advance directives

19
42 CFR 489.102Hospice Regulation, cont.

• Provide for education of staff regarding
  facilitys policies and procedures on advance
  directives
• Provide for community education regarding the
  right under State law to formulate an advance
  directive and facilities written policies and
  procedures regarding the implementation of these
  rights, including any limitations on the basis of
  conscience.

20
FYI !!!!!!!

• The facility is not required to provide care that
  conflicts with an advance directive.
• The facility is not required to implement an
  advance directive if, as a matter of conscience,
  the provider CANNOT implement an advance
  directive and state law allows the provider to
  conscientiously object.

21
19 CSR 30-88.010 (9)State Regulation

• Prior to or upon admission and at least
  annually after that, each resident or guardian
  shall be informed of facility policies regarding
  provision of emergency and life-sustaining care,
  of an individuals right to make treatment
  decisions and of state laws related to advance
  directives for health-care decision making.

22
State Regulation, cont.

• If a resident has a written advance health-care
  directive, a copy shall be placed in the
  residents medical record and reviewed annually
  with the resident, unless, in the interval, the
  resident is determined to be incapacitated.

23
State Regulation, cont.

• Residents guardian or health care
  attorneys-in-fact shall be contacted annually to
  assure their accessibility and understanding of
  the facilities policies regarding emergency and
  life-sustaining care.

24
Goal Setting Categories

• Rehabilitation
• Maintenance
• Prevention
• Palliative
• The IDT should determine the overall goal of care
  with the resident/legal surrogate.

25
Palliative Care Goals

• Palliative care becomes an overall goal for the
  resident during the end stages of life, but
  specific interventions will be needed to attain
  an appropriate level of functioning, to maintain
  the residents highest quality of life, and
  prevent suffering.

26
Recognize the Need to Revise Goals

• Residents who spend years in facilities must have
  ongoing assessment to determine change of
  condition and the need to revise goals of care.
• The IDT must recognize and discuss the slow
  decline in the resident with a chronic disease.
• The IDT can have purposeful conversations with
  the resident/responsible party and set realistic
  goals for resident care.

27
The MDS and Goal Setting

• Several MDS items help staff recognize the need
  for decisions about goals, however, the most
  significant is
• Section J5c
• end-stage disease, 6 months to live
• A doctors certification that the resident has
  six months or less to live must be present in the
  record before coding the resident as terminal.

28
Other Noteworthy MDS Items

• Section A10 Advance Directives
• Section B6. Change in Cognitive Status
• Section C7. Change in Communication
• Section E3/ E5. Change in Mood/Behavior
• Section G9. Change in ADL Status
• Section H4. Change in Urinary Continence
• Section Q2. Overall Change in Needs

29
Other Noteworthy MDS Items, cont.

• Section J1,2, 5. Problem Conditions, Pain
  Symptoms, and Stability of Condition
• Section K3. Weight Change
• Section M1. Pressure Ulcers
• Section P1, 5, and 6. Special Treatments and
  Procedures, Hospital Stay(s), and ER Visits

30
Significant Change in Status Assessment (SCSA)

• RAI Manual, Version 2002, clarification
• The key in determining if an SCSA is required
  for individuals with a terminal condition is
  whether or not the change in condition is an
  expected well-defined part of the disease course
  and is consequently being addressed as part of
  the overall plan of care for the individual.

31
Complete a SCSA

• For a newly diagnosed resident with end-stage
  disease when
• - a change is reflected in more than one area of
  decline and
• -the residents status will not normally resolve
  itself, and
• -resident requires IDT review and/or revision of
  the plan of care.

32
Complete Subsequent SCSAs

• Complete subsequent SCSAs based on the degree
  of decline and the impact upon the care plan.
  Consider the following
• -completion of the last MDS
• -clinical relevancy and accuracy of the MDS to
  the residents current status and
• -the need to change the care plan to reflect
  current status.

33
Regulatory Compliance forGoals of Care

• 19 CSR 30-88.010 (11) Each resident shall be
  afforded the opportunity to participate in the
  planning of his/her total care and medical
  treatment, to refuse treatment.
• Federal Regulation For the resident to receive
  the necessary care and services to attain or
  maintain the highest practicable physical,
  mental, and psychosocial well-being in accordance
  with the comprehensive assessment and care plan.

34
Factors That May Lead toAbuse and Neglect

• Centers for Medicare and Medicaid Services (CMS)
  identifies isolation as a consistent predictor
  of abuse and neglect.
• The resident may become isolated not only
  because of cognitive and physical dependency, but
  also because staff may feel inadequate in dealing
  with the dying resident.

35
Avoidable vs UnavoidableOutcomes

• State Operation Manual (SOM) consistently directs
  the surveyor to determine if negative outcomes
  are avoidable or unavoidable.
• Residents at EOL often have negative outcomes,
  but they may be avoidable.
• Ongoing assessment, care planning, implementation
  and revision are elements that determine
  avoidable or unavoidable.

36
Documentation

• Purposeful observations and conversations
• Information about values and beliefs
• Ongoing purposeful observations and conversations
  and documentation revised to reflect ongoing
  information.
• IDT should amend instruction to caregivers.
• Symptoms should be assessed, interventions
  initiated, and evaluated in documentation.

37
Case Study

• Mrs. Smith
• Subsection 2.7 Mrs. Smith
• Guidelines for End-of-Life Care in Long-Term
  Care Facilities

38
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