The Advance Care Plan / Long-Term Care Directive

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 our proprietary 4-Needs™ Advance Medical Directive (part of almost every level of planning we offer) which includes our proprietary Long-Term Care Directive™. The Long-Term Care Directive™ helps you organize, store and disseminate information provided by you as part of the 4-Needs™ Advance Medical Directive, in order to better serve your future long-term care needs and to guide those who you will depend or for future care. The Long-Term Care Directive™ identifies your specific needs, desires, habits and preferences and guides your caregiver in a unique manner. A Long-Term Care Directive™ should be created as part of your incapacity plan, Estate Plan, of Asset Protection Plan, because the best person to create a care plan for you is you. Here’s an example of someone with and without a Long-Term Care Directive™.

Jill, 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 because, like many stroke victicms, she has speech aphasia. She is able to feed herself for the most part.

Without a Long-Term Care Directive™ With a Long-Term Care Directive™
5:30 AM: Awakened. Pajamas taken off, given some quick care, dressed for the day in someone else’s dress. It is a pretty dress, but she does not like dresses. She prefers to stay in her pajamas and simply put on a robe. 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 one of her favotire TV shows on to await breakfast. Stays in her favorite pajamas and a robe since it is a shower day.
7:30AM: Taken to the dining room for breakfast. Given one cup of black coffee; non-dairy creamer and sugar are available, so she uses them even though that’s not her preference. She is not offered a second cup of coffee. She is not served bacon or eggs due to her high cholesterol and the fac that her doctor has her on a restricted diet. 7:30AM: Served breakfast. Served bacon and eggs. Her cholesterol is still high but she stated her wishes to eat a regular diet in her Long-Term Care Directive™. She has her two cups of coffee, sweetend with one packet of Sweet ‘N Low and lightened with half and half, as she has done for the last 65 years.
After Breakfast:

Jill is taken to sit in the hallway outside of her room.

After Breakfast: Jill is taken to the bathroom to shower. This is her first shower day this month, so her underarms and legs are shaved with an electric shaver as requested in her Long-Term Care Directive™. Her hair is washed with the same shampoo she has used for the last twenty years, as requested in her Long-Term Care Directive™. After her shower, she is dressed the way she has directed in her Long-Term Care Directive™.
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 favorite flavored 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 Long-Term Care Directive™ notes that the staff should help her moisten her lips frequently.
10:00 AM: Given six pills: Two for high cholesterol, one for irregular heartbeat, one to prevent heart burn, one for hypertension, and one for arthritis. 10:00 AM: Given three pills: One to prevent heartburn, one for hypertension, and one for arthritis. She had decided in her Long-Term Care Directive™ not to take her cholesterol medication or her irregular heartbeat medication if she entered a nursing home for a long-term stay.
11:00 AM: Still sitting in the hall by the nurse’s station. 11:00 AM: Taken outside to sit in the shade. Jill 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 Long-Term Care Directive™ 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. Jill 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. Jill 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 Jill 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.

© Advance Care Planning, Inc.