The COVID pandemic was a brutal lesson on the importance of having an advance care directive in the event of a sudden health crisis. But advance care planning goes beyond whether or not an individual wants to be put on a breathing tube, said Kristin Stevens, RN, NP, Lifespark APP Supervisor. “Identifying end-of-life wishes is just a small part of a much larger discussion,” she said. “The core elements of advance care planning include contingency planning to prevent unnecessary ER visits and hospitalizations, and learning our members’ preferences for how they want to live their lives.”
Contingency planning
The best time to create a contingency plan is before there’s a health crisis. “At the start of the journey with our Lifespark COMPLETE members, we encourage them to help us build contingency plans to keep them off what we call the ‘sick care crisis roller coaster’,” Kristin said. “A contingency plan can include what changes to watch for, what medications to take based on their symptoms, and when to call us.”
Having a plan in place allows members to direct their care, in collaboration with their Life Management team. In senior living, that team includes an advance practice provider (APP) who is usually a nurse practitioner (NP), the Lifespark medical doctor, and the clinical liaison, typically a licensed practical nurse (LPN).
“Our contingency plans aren’t that different from an asthma action plan for kids that uses the colors of a traffic light to indicate the medication, dose, and action, based on the severity of their symptoms,” Kristin explained. “For clients with heart failure, for example, their plan will include a goal weight range, and if they notice their weight is two pounds above or below that range, they know whom to call at Lifespark and whether they should take additional diuretics.”
If a member calls after hours, the triage team can immediately access their contingency plan via their electronic medical record and guide them through each step of the intervention.
Priorities and preferences
Another component of proactive planning focuses on individual goals, priorities, and preferences. “We use the ‘7 Elements to COMPLETE SENIOR HEALTH’ to learn what matters most to our members and how they want to live their lives,” Kristin said. “Health is certainly a part of our whole-person model, but aging magnificently is also about purpose, belonging, finances, home, community, and other elements of well-being.”
If volunteering is meaningful to the member, their Life Management team can help them find a way to give back to their community. If the member is craving mental stimulation, they might be encouraged to join a book club or discussion group. If they need motivation to stay active, their team can collaborate with them to set goals, find an exercise buddy, or participate in the Spark Challenges in their community. And if they haven’t yet created an advance care directive, that will definitely be part of their advance care planning.
Overcoming barriers
Talking about advance care planning can be a tough conversation. Some seniors feel they’re too young or too healthy, while others find the topic too emotional. “There’s a fair amount of anxiety about aging and what lies ahead,” Kristin said. “But more often, what seems to hold elders back from discussing their late-life wishes is fear of causing grief for their family.”
In some cases, that fear is rooted in a misunderstanding of what proactive planning is. According to Kristin, one of the things that sets Lifespark apart is being able to take the time to explain the difference between a POLST (physician orders for life-sustaining treatment), a health care directive, and advance care planning. “For example, if one of our members sees a lot of different specialists and it’s getting harder for them to get to their appointments, their advance care plan could allow the member’s Life Management team to step in as their primary care provider,” she said.
In the clinic setting, providers just don’t have time to delve into the nuances of proactive planning, whereas Lifespark can set a cadence for these discussions, Kristin explained. “We can introduce the topic at an initial visit, bring it up again a week later, and as we get to know the member and their family, we can devote a whole visit to life planning,” she said. “The question we continue to ask is, ‘What do you want your journey to look like?’”
Benefits of planning
Talking about the benefits of advance care planning can also help overcome resistance, Kristin said. Among those benefits: Knowing what to watch for and what actions to take means fewer trips to the emergency room. Having these discussions while the member is still relatively healthy allows for thoughtful, comprehensive planning. Making decisions before there’s a health emergency relieves stress for the member and their family.
Another important benefit of proactive planning is the acknowledgement that aging is a life stage, not a death sentence, Kristin said. “Just having these conversations helps prepare us for the challenges and the opportunities we’ll have along this journey,” she said.
Three tips for members and families:
- Learn about your loved one’s health challenges.
“It’s important to educate yourself on the progression of your loved ones’ chronic conditions,” Kristin said. “If mom and dad still live on their own, don’t wait until they’re unable to walk before discussing assisted living or in-home care, and the financial considerations of each option.”
- Have open, honest, and ongoing conversations.
“As uncomfortable as it might feel, it’s a lot easier to discuss expectations and preferences—yours and theirs—when the family isn’t in the throes of a medical crisis,” she said.
- Review the plan regularly.
“It’s important to revisit your care plan on a regular basis and whenever there’s been a change or an event—death of a spouse, move to assisted living, new diagnosis or medication, ER visit, or hospitalization,” Kristin said. “Just as we all keep changing and evolving, so should the plans that support us on our journey.”
To learn more about Lifespark’s approach to complete senior health, visit Lifespark.com or call 952-345-8770.