Advance Care Planning with Frail Elders
The American Medical Directors Association (AMDA) strives to keep all of us in long-term and post-acute care well informed on best practices for the population we serve and those cared for by their Medical Directors. This week, their timely guidance was on the value and importance of having a standard national advance care planning form for frail elders to communicate their treatment preferences. This form, familiar to many as the POLST (or MOLST in some states) summarizes the wishes of the resident and while always of value in urgent health crisis it is particularly valuable in the current pandemic where the frail nursing home resident may deteriorate suddenly, and decisions need to be made quickly. In this frequent scenario, knowing the risks and benefits of care, as well as the resident’s wishes, are of paramount importance.
In a companion article in Choosing Wisely, one of ten admonitions for professionals in PALTC states clearly:
“Don’t recommend aggressive or hospital-level care for a frail elder without a clear understanding of their goals of care and the possible benefits and burdens.”
For some frail elders, the balance of benefits and harms of hospital-level care may be unfavorable. To avoid unnecessary hospitalizations, care providers should engage in advance care planning by defining goals of care for the patient and discussing the risks and benefits of various interventions, including hospitalization.
Stories from the Field
The identification of frailty and completion of Advance Care documents are central to clinicians and facilities using Patient Pattern software.
Darryl was 32 years old and had a Frailty Risk Score indicating his “true physiological age” was 103. He was new to our vent-unit, having spent over 400 days in the hospital following a boating accident and a traumatic brain injury. He had no advance care documents and so his Mother became his legal guardian and in the hospital everything was done for him to keep his organs functioning in hopes of recovery. After this long hospital stay, without progress or hope of recovery, he was discharged to our facility and upon admission, from the Minimum Data Set completed, a Frailty Risk Score was calculated, indicating “severe frailty”. Our usual next step was to schedule a family meeting to discuss the assessment and the plan of care management we thought appropriate and to ascertain their priorities, expectations, and goals of care. With some concern we scheduled the meeting, wondering how the family would receive the news.
The family members arrived as a unit, each appearing apprehensive and worn out yet trying to remain hopeful that this new setting might be able to work wonders for their son and brother. They listened to our doctor, a Geriatrician, carefully and kindly explain frailty and all the aspects of Darryl’s condition that contributed to the calculation of frailty. They understood his inability to breathe without the vent, or do any care for himself, or talk or communicate in any meaningful way. They were dismayed by the hospital-acquired bed sores, the associated pain he was experiencing, and knew there was a risk they would get bigger or infected. And they also knew that their son was unlikely to recover or return to a life with quality and were relieved when given the opportunity to each share their expectations and priorities for his care.
They began to build trust with our professionals quickly and appeared to be eager to complete Advance Care documents when given the opportunity – even at this first meeting. And so, his Mother gave permission for a DNR order to be written and completed a MOLST form with input from other family members.
Sadly, there were no miracles for Darryl and one complication after another occurred but there was more quality in the lives of his family as they were at peace with their decision and knew while very hard to make it was the best they could do for their son and brother. They were clear on their desire to avoid another hospital stay and glad they were given honest and meaningful information about Daryl’s status and the opportunity to put their wishes for him into a document to protect him from further aggressive care.