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Advance Care Planning Resources for Clinicians

An individual's goals, values and preferences for future healthcare evolve over time. Gundersen Health System follows the Respecting Choices evidence-based model for advance care planning (ACP). This staged approach to planning (First, Next, and Last Steps) is designed to meet the needs of individuals over the course of a lifetime as goals, values, and health status changes.

Stages of Planning

First Steps® is appropriate for any healthy adult over the age of 18 and for those may have a well-managed chronic illness but has never prepared an advanced care plan. The goals of this stage are to assist in selecting a qualified healthcare agent(s), discuss goals of care in the event of a severe, permanent brain injury and complete a written advance directive. 

Next Steps is offered to patients when chronic illness begins progressing such as experiencing increased complications, more frequent hospitalizations/clinical encounters and/or a decline in function. The goals of this stage of planning are to assess the patient's understanding of the disease progression (and related treatment options), discuss what matters most (goals and values) and to identify care preferences in bad-outcome situations. While it is assumed that full care and treatment will continue, Next Steps conversations help to clarify when goals of care would shift based on the patient's clarification of unacceptable outcomes. This more in-depth conversation helps patients think about choices and decisions they may need to make in the future, identify needed services to support living as well as possible and prepare healthcare agents for a future decision-making role.

Last Steps® is a component of quality end-of-life planning intended to elicit, document and honor the treatment preferences of seriously ill or frail individuals. Last Steps certified facilitators assist individuals in making informed treatment decisions that are consistent with identified goals and values within the context of their current medical condition. Those decisions are then converted into portable medical orders using the Provider Orders for Scope of Treatment (POST) form that can be followed across care settings including emergency personnel in the community.

The role of the facilitator

The (ACP) facilitator is an emerging role in healthcare. ACP facilitators are trained to guide individuals and their loved ones through person-centered conversations, reflecting upon and discussing preferences for future healthcare decisions. ACP Facilitators are a critical component to achieving the ACP desired outcome—to know and honor an individual's healthcare decisions. ACP Facilitators motivate individuals to plan and ease the planning process.

ACP facilitators are trained to have conversations with individuals at different stages of health and in different settings of care. The value of the facilitator role is demonstrated through:

  • Timely and appropriate referrals for ACP services,
  • The person-centered decisions individuals and families are assisted in making,
  • Overwhelmingly positive individual and family satisfaction, and
  • Professional competence and confidence in providing skilled facilitation and delivering care that is consistent with an individual's goals, values, and beliefs.

Our patients tell us:

"I feel so much better about my future healthcare decisions after talking about it. I would advise everyone to do this."

"I am better prepared now. Without this conversation, I could be stuck guessing what my loved one wants."

"The facilitator set me at ease, was very kind and easy to talk to. All of our concerns and questions were answered fully."

ACP facilitator certification: Gundersen in partnership with Mayo Health System supports the ACP Facilitator role by offering First Steps Facilitator Certification twice annually. For more details or to register, download the brochure.

Provider Orders for Scope of Treatment (POST)

POST is a system to convert patient preferences for future healthcare into portable medical orders that emergency personnel can follow. POST helps ensure treatment preferences for a medical emergency can be known and honored in the community and across healthcare settings.

POST is not for everyone. POST is appropriate for individuals with serious illness or advanced frailty nearing the end-of-life. POST is also for patients who reside in long-term care facilities and for persons of advanced age who want to communicate their wishes for life-sustaining treatment in a medical emergency.

The POST form is completed as a result of an informed, shared decision making conversation. The patient discusses his/her goals, values, and beliefs and the health professional provides medical information. Together they reach an informed decision aligned with the person's values and goals for care.

The POST form does not replace an advance directive. POST and advance directives support each other but do different things. All adults should have an advance directive which allows for appointing a healthcare agent and providing instructions for future care.

Gundersen Health System follows the National POLST paradigm guidelines. For more information go to www.POLST.org

If you have questions related to the POST form or would like to learn more about becoming an ACP facilitator, contact Danielle Rathke, Advance Care Planning coordinator at ext. 56000 or email darathke@gundersenhealth.org.

Love + Medicine

Every day, Gundersen Health System staff deliver great medicine plus a little something extra—we call it Love + Medicine.

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