Advance Care Planning in Post-Acute and Long-Term Care

An Ongoing, Person-Centered Process

Advance care planning (ACP) is much more than completing an advance directive or checking a box at admission. It is an ongoing, person-centered process that helps ensure a resident’s goals, values, and preferences guide healthcare decisions throughout their stay. It typically unfolds through ongoing conversations among the resident, their family, and members of the care team, and may result in the appointment of a legal healthcare decision-maker as well as formal documents such as advance directives.

In post-acute and long-term care settings specifically, ACP should address several important components, including a healthcare proxy, living will, do not resuscitate (DNR) and do not intubate (DNI) orders, goals of care, and spiritual and cultural considerations.

A Collaborative Approach to Planning
ACP should be initiated upon admission and continue throughout a resident’s stay. An interdisciplinary approach is best, as each member of the care team brings a unique set of skills and perspectives to the conversation. Involving the resident’s family or representative is also important. Because generic ACP forms can sometimes result in a “check-the-box” task rather than a meaningful conversation, researchers have developed nursing-home-specific ACP tools designed to help structure the conversation itself — not simply document its outcome. The American Association of Post-Acute Care Nursing (AAPACN) also offers a growing library of free, downloadable tools created by nurse experts.

The Benefits of Meaningful Advance Care Planning
Facilities that treat ACP as an integral part of their care model — rather than simply a compliance formality — can realize tangible benefits. Aligning clinical orders and interventions with a resident’s documented advance care plan can help reduce unnecessary hospitalizations for conditions that may often be managed on-site, such as urinary tract infections. It can also spare families the burden of making high-stakes decisions during an acute crisis, because important conversations and decisions took place in advance, during a more stable time.

Adapting as Needs and Wishes Change
Using ACP does not mean plans have to be set in stone. A resident’s goals, preferences, and course of care may change over time. However, ACP helps ensure that changes are thoughtful, informed, and clearly communicated rather than driven by the urgency and uncertainty of an emergency.

Ultimately, ACP works best as a facilitated, recurring conversation grounded in a resident’s individual values, goals, and preferences — not as a form completed once at admission and never revisited.

Affinity’s experienced team of clinical experts can help guide your facility through the ACP process. Visit our website to learn more, or call us today to schedule a free consultation!