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The Advance Care Plan

Federal law requires every long-term care facility to create a care plan.  The care plan begins with a baseline assessment, which should occur within two weeks after a resident moves into the new facility, by a team from the nursing home (which may include a doctor, nurse, social worker, dietician, and physical, occupational, or recreational therapist).  This team will use information provided by the resident and the family about the resident’s medical and emotional needs to generate this baseline assessment, which then becomes the yardstick against which the caregivers can measure the resident’s progress.

You can help by making a list of your loved one’s medical, psychological, spiritual, and social needs, as well as his or her preferences and usual routine.  For example, you might give the staff the following type of information: “Dad likes to listen to classical music on the radio as he falls asleep” or “Mom’s always been a night-owl; she goes to sleep at around 1 a.m. and wakes up at 10am.”  You should also note signs of depression, or symptoms of dementia.  Since the assessment team does not know your loved one as well as you do, your input may be invaluable, especially if the resident is not able to provide meaningful input.  Although development of a care plan is something required to be done by a nursing home, a care plan can, and ideally should, be created in advance, well before the need for nursing home care.  By planning in advance, when you have a clear mind and the ability to communicate effectively, you can much better guarantee that your wishes, lifestyles and desires are documented and will be communicated to your future caregivers, whether these be family members, private nurses, home health aides, or staff in a nursing home. 

The easiest way to develop your own care plan is to use a tool such as the Advance Care Plan, created by Advance Care Planning, Inc.  The Advance Care Plan is a proprietary document that is created by special software that gathers, organizes, stores and disseminates information provided by you in an interview, in order to better serve your future healthcare needs and to guide those who you will depend or for future care. The Advance Care Plan identifies your specific needs, desires, habits and preferences and guides your caregiver in a unique manner. An Advance Care Plan should be created as part of your basic Estate Plan or as part of your Long- Term Care Plan, because the best person to create a care plan for you is you.  The following example is provided by Advance Care Planning, Inc. of how an Advance Care Plan can help improve a day in the life of Lynn, a typical nursing home resident:

Lynn, at the age of 85, has been placed in the nursing home due to a stroke. She is incontinent, but if taken to the restroom at appropriate times she will be continent most of the time. She is alert, but somewhat confused at times. She very much knows what she wants but cannot always verbalize it. She is able to feed herself finger foods.

Without an Advance Care Plan

With an Advance Care Plan

5:30 AM: Awakened. Hospital gown taken off, given some quick care, dressed for the day in someone else's house dress. It is a pretty house dress, but she does not like house dresses.

7:00 AM: Awakened. Taken to the bathroom for quick morning care, then placed in a comfortable chair in her room in front of the TV with a requested show on to await breakfast. Stays in her short PJ's and a robe since it is a shower day.

7:30AM: Taken to the dining room for breakfast. Given one cup of coffee, not offered more coffee. Not served bacon due to her high cholesterol.

7:30AM: Served breakfast. Served bacon and eggs. Her cholesterol is still high but she stated her wishes to eat a regular diet on her Advance Care Plan. She has her two cups of coffee, as she has done for the last 65 years.

After Breakfast: She is taken to sit in the hallway outside of her room.

After Breakfast: Taken to the bathroom and then to shower room. This is her first shower day this month, so her underarms and legs are shaved per her Advance Care Plan. Her short hair is washed, as it is with every shower. She prefers to shower in the morning. After her shower, she is dressed in a navy blue jogging suit with a red tee shirt, per her Advance Care Plan.

About 1-2 hours Later: She is taken to her room, has her brief changed and then is set in the hallway by the nurse's station. Her lips were not moistened, nor does she have access to chapstick.

About 1-2 Hours Later: She has her chapstick around her neck and is able to put it on herself frequently. Though her lips do not look dry, they feel dry to her. Her Advance Care Plan notes that the staff should help her moisten her lips frequently.

10:00 AM: Medication. Given six pills: Two for high cholesterol, one for irregular heartbeat, one for hiatal hernia to prevent heart burn, one for hypertension and one for arthritis.

10:00 AM: Given three pills: One for hiatal hernia to prevent heartburn, one for hypertension and one for arthritis. She no longer takes the pill for her irregular heartbeat as this does not create a problem for her. She has chosen not to take her cholesterol medication, as stated in her Advance Care Plan. She had decided in the past that if she entered a nursing home for a long-term stay, she would prefer not to take the majority of her medication.

11:00 AM: Still sitting in the hall by the nurse's station.

11:00 AM: Taken outside to sit in the shade. Lynn does not like crafts, but prefers to be outside in the shade, weather permitting.

12:00 Noon: Taken to the dining room for lunch. Given a lean hamburger, no salt allowed, a salad with lowfat dressing and applesauce. She needs assistance with the applesauce.

12:00 Noon: Taken back to her room for lunch; placed in her chair in front of the TV with her program of choice. Given a cheeseburger, packets of salt, french fries and apple slices. She has stated in her Advance Care Plan that she does not want to be fed and would prefer mostly finger foods.

After Lunch: Taken to the nurse's station to sit in the hallway.

After Lunch: Taken to the restroom and then placed in her recliner to rest and watch a movie on her DVD player. The movie is Pretty Women, a movie she has seen 50 times. She would like to see it 50 more.

2:00 PM: Placed in bed to have brief changed, and rest.

NONE

3:30 PM: Placed in wheelchair and taken to ceramics class.

3:30 PM: Gets her weekly manicure instead of going to ceramics class. Lynn does not like crafts.

5:00 PM: Taken to room to have brief changed.

5:00 PM: Taken to the restroom. Prepared for dinner.

5:30 PM: Taken to dining room for dinner. Served chicken. Lynn loves hot dogs but they are not served due to her high cholesterol.

5:30 PM: Placed in her chair in her room for dinner. Served hot dogs with green pepper slices, cherry tomatoes and veggie dip. Enjoyed a brownie for dessert. per her Advance Care Plan, she likes finger foods.

After Dinner: Taken to the nurse's station to sit in the hall. There is a TV with DVD at the nurse's station; staff puts a movie on for those sitting in the hall to watch. The movie is Lord of the Rings, which Lynn has seen several times and does not like.

After Dinner: She continues to watch TV until 7:30 PM.

8:30 PM: She is taken to the shower. She prefers to bathe in the morning.

7:30 PM: She is taken to the bathroom and helped to prepare for bed. She wears her short pajamas per her Advance Care Plan.

After Shower: She is dressed in a hospital gown and put to bed with one pillow at her head.

8:00 PM: She is placed in bed with a talking book. It is a legal mystery, the type of book she likes. She has stated in her Advance Care Plan that she wants to go to bed by 8:00 PM to read. She is only able to make use of talking books at this time.

The room is 75 degrees and she is very warm. She throws her covers off since she is too warm to sleep. The staff does come in and turn her several times. They place her on her back (she has never been able to sleep on her back) and they always cover her back up. Her brief is changed.

In bed, she has down pillows (5 ft.) on either side of her, between her legs, and 3 at her head, as she has slept for 40 years. The room temperature is 70 degrees, which is slightly warm for her. The temperature cannot be adjusted due to her roomate, so her personal fan is turned on her to keep her cooler. She sleeps well but is awakened by the staff twice to take her to the toilet, per her Advance Care Plan. She remains continent at night.

The following day, she falls asleep in her chair by the nurse's station since she did not sleep well the night before. Her children come to take her out to lunch but she appears too sleepy so she does not go.

The following day she is rested and has a strong sense of well-being. Her children come and take her to lunch. She is gone several hours, and rests in her chair for two hours upon her return.