In 2004 and 2005, pilots and partnerships with both the Renal and Residential Care programs were initiated and both continue to be ACP leaders in our health authority. In the Renal Program, a nurse was hired 1 day per week to engage in ACP conversations with patients and families. Included in a renal pilot were 35 patients who had been on dialysis an average of 31 months and were on average 64 years of age. ACP conversations took place over time and averaged 2 hours in length. The pilot concluded that with this type of intervention:

■ 86% of patients had an ACP on their chart,

■ 100% of patient wishes were honored; patients and families stated they felt relief and gratitude following engaging in ACP. While this was certainly successful, in retrospect, the hiring of a specific person hindered embedding ACP into all clinicians' practice. Additionally, this funding was not continued and, as a result, sustainability was not achieved. Funding for an EOL and ACP Coordinator for the Renal Program was secured for 2 years. This person does not engage in ACP conversations directly with patients but, rather, coordinates implementation among the teams and regional program.

From 2006 to 2007, the FHA embarked on a pilot program to implement ACP in a single community to further gain experience prior to implementing across the health authority. The goals were to implement in all health sectors including acute, residential, and community care programs and to promote it in the public sector by placing information and materials in areas such as libraries and community centers. From our experience, implementing in a single community across all sectors and care delivery settings is more successful than implementing in single program areas such as a hospital or renal care center. Insights from this pilot showed the public is interested and eager to engage in ACP as illustrated by the number of community presentations requested. Physicians were open to engage in ACP with patients, particularly those with shortened life expectancy, and health records departments were willing to file documents. The pilot also provided the following information, which assisted the growth of the program: More physician offices needed to be engaged, communication between hospital and home health needed to be enhanced, and community information/education was vital.

Summary of Continuous Quality Improvement

■ Successes are measured one unit/program, sometimes one clinician, at a time.

■ Patient competence/capacity was a barrier and, as such, residential care was a difficult place to begin ACP.

■ Work together as a team to respond to ACP roles and responsibilities.

■ Support programs (e.g., our Renal Program) have grown and adapted into successful examples and provide opportunities to share with other programs.

■ Never give up on learning and adapting; pace change; set small, achievable goals.


Whose Role Is It Anyway?

One of the challenges faced includes the long-standing myth that ACP is a role exclusively for physicians. Other successful ACP programs have implemented a facilitator role where this person's job is to accept referrals
and engage in ACP conversations with patients and families. Due to lack of resources, we have not been able to fund a role such as this. As a result, the FHA promotes and supports an interdisciplinary approach to ACP conversations. While it has been a challenge to delineate the roles of nurses, social workers, spiritual health practitioners, respiratory therapists, and other allied health professionals, the development of our five Core Elements of ACP conversations have assisted these professionals to work out who is doing what with a particular individual. (For more information, see fraserhealth. ca/professionals/advance-care-planning/) These elements are:

1. S.P.E.A.K. to adults about ACP.

2. Learn about and understand the adult and what is important to him/ her. Involve substitute decision makers.

3. Clarify understanding and provide medical information about disease progression, prognosis, and treatment options.

4. Ensure interdisciplinary involvement and utilize available resources/ options for care.

5. Define goals of care; document and create a plan (including potential complications).

Some programs do not employ allied health professionals, such as social workers; therefore, nurses' scope of practice may include Core Element 2 as well as 3.

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