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Since 2005, with the support, wisdom, and guidance from the ACP Steering Committee, we began to develop a variety of tools and resources that proved to be foundational to the success of our program. These resources were developed over the course of several years and with one-time money.

Resource Development

In 2005, work began on the first iteration of the Fraser Health My Voice Workbook. This workbook was modeled after Respecting Choices. It was finalized in 2006 and has been pivotal to our program. It has often been said
that the Fraser Health My Voice Workbook was developed “by the public for the public.”

The last page of our workbook, “Expressing Your Wishes,” is referred to as the “heart page,” and it is suggested individuals complete this first before other engagement in the ACP process. People are asked to reflect on and write about the following:

■ When I think about death, I worry about the following possible situations: For example, “I worry I will struggle to breathe,” or “I worry that I will be alone.”

■ If I am nearing my death, I want (and/or do not want) the following: For example, “I want soft music playing,” or “I want someone to hold my hand,” or “I want my minister or priest to perform the necessary religious rituals.”

■ When I am nearing my death and cannot communicate I would like my family and friends to know and remember these things: For example, “I love you” or “I forgive you.”

This workbook is complemented by two brochures: Making Informed Choices about CPR and Information Booklet on Advance Care Planning. These publications as well as the workbook were translated and are available in English, Punjabi, and Chinese.

Educational DVDs were also produced at this time. These are also available in the above-noted languages. The DVDs have been utilized in patient education sessions, community presentations, as well as for health care professional learning sessions. These DVDs are available in all of the libraries in British Columbia, all libraries in our health authority, as well as on the Internet. Clinicians have also utilized these DVDs in one-to-one sessions with patients and families, some of whom are struggling with engaging in the ACP process.

Posters are also available in seven languages. These have proven effective when placed in physician offices as well as public areas in hospitals and clinics. Posters have basic information about ACP, contact information, and a suggestion to speak with your physician. An ACP e-mail address and toll-free telephone number for the public is available and included on all printed resources. All resources have been made available on our Fraser Health website ( planning/), which has been an effective dissemination strategy for the community/public.

The My Voice Workbook as well as the brochures have been adapted in various countries. Fraser Health has shared their resources and has formal letters of agreement with health organizations throughout Canada, the United States, New Zealand, and Singapore.

Policy and Medical Orders

In 2006, a regional CPR and do not resuscitate (DNR) policy came into effect for acute care settings. The policy included some elements of ACP. Building our ACP program, including policy, has been incremental in nature. The ACP elements that were included in the CPR/DNR Policy were the implementation of the Greensleeve, Greensleeve processes, and ACP Record. A Greensleeve is a green page protector that is kept at the front of binder charts and holds ACP materials. The ACP Record is a communication tool that all health care professionals can document on and provide a quick look at where people are in the ACP process. The early introduction of both the Greensleeve and ACP Record proved pivotal in the coming years.

An audit of the policy, DNR form, and Greensleeve processes in our 12 acute care sites from December 2009–April 2012 provided the following data:

■ 62% of patient charts had Greensleeves.

■ 45% of patients had a DNR.

■ Of those patients with a DNR:

● 80% wanted medical treatment but no Critical Care Interventions.

● 10% wanted Critical Care Interventions.

● 8% wanted comfort measures.

● 2% had specific instructions not captured on our form.

■ 83% of physicians had spoken with someone prior to completing the DNR.

● 41% had documented the conversations.

Additional audit information that assisted in the further development of policy and implementation strategies included the following:

■ The ACP Record form was not being consistently used in acute settings; however, social workers and physicians often noted conversations in their respective chart sections.

■ The DNR form provided a place to document refusals only, not wishes.

■ Greensleeves did not house ACP documents, but held only DNRs.

■ Many patients in acute settings had multiple acute admissions and multiple programs involved in their care, which added to the complexity of care planning and illustrated the need to improve communication among providers.

Building on the CPR/DNR Policy, in 2010, the Executive Team approved the Making the MOST of Conversations: Medical Orders for Scope of Treatment (MOST) initiative ( care-planning/). A variety of clinicians had, throughout the years, identified the need to standardize resuscitation status and medical intervention
policy and language in all sectors of care, particularly residential and acute care. A physician focus group was convened in 2007 to begin the initial thoughts surrounding this policy and form.

Throughout 2010 and 2011, focus groups were held with over 200 clinicians to begin revisions and changes from the current CPR/DNR to the MOST policy and form. Key learnings from these focus groups included the following:

■ General awareness in all groups of the concept of ACP and need for conversations. Wide variation on what people considered as ACP, for some it was specifically a DNR discussion, for others understanding was full scope;

■ Consensus that there are many layers of education and information required within the health authority; for example, promoters, supporters and responders. Most groups supported ACP to become part of all assessments and admissions processes.

Key challenges identified included:

■ Time and resources for conversations

■ Patients' lack of information regarding diagnosis, prognosis, and information about illnesses and/or interventions

■ Health care professionals' lack of legal understanding, most notably substitute consent

■ Transfer of information between health care professionals and programs has been fragmented

Summary of System Infrastructure

■ ACP is first and foremost about the messages we hold in our hearts.

■ Develop resources and materials as finances prevail.

■ Public input is invaluable and resources should be user-friendly and in plain language.

■ Incremental policy development builds upon implementation experience.

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