Advance Care Planning
Our intervention was designed to enhance chronic disease management. Chronic diseases are characterized by fluctuations in stability and have disease specific trajectories. Patients were within various stages of disease.
Planning ahead allows the patient and family to discuss the goals and wishes more fully. Advance care planning discussions can happen at any time and should be revisited as the patient’s condition, goals of care, and wishes change.
For the trial, we educated front line staff to become familiar with the Speak Up campaign, having difficult conversations and initiating the discussion. Previously, our Catalyst trial used a psychosocial counsellor.
Why is advance care planning important?
Chronic disease guidelines and best practices recommend advance care planning and goals of care discussions to adequately prepare for the patient’s disease trajectory and illness progression. Care coordinators and nurses are trained to begin discussions with patients regarding their health goals and care wishes, and includes identification of a substitute decision maker. A social worker or psychosocial support counsellor possess the recommended skills to support and augment discussions for more complex patients. Standardized tools such as A Guide to Advance Care Planning and Speak Up best capture the appropriate information to be shared with family and health care providers.
