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April 23, 2020

4 barriers to advance care planning during Covid-19—and how nursing homes can overcome them

Daily Briefing

    Advance care planning provides individuals the opportunity to determine and document their own care goals and plan for future interventions, should they need them. While these discussions are always critical to ensuring patients' and families' wishes are met, the Covid-19 epidemic has only added further urgency, as the disease can render patients unable to communicate.

    Nursing homes: The front line in the fight against Covid-19

    The unpredictability of Covid-19 means patients can deteriorate quickly—and that can be particularly important for older individuals and those with serious pre-existing medical conditions. According to World Health Organization data, the average death rate from Covid-19 among elderly patients ranges between 15% and 22%—five times that of the general population.


    That's why skilled nursing facilities (SNFs) must prioritize advance care plan (ACP) discussions and documentation in their Covid-19 response as almost all of their residents are at substantial risk. This is admittedly easier said than done, particularly because the epidemic creates new, and exacerbates existing, challenges that SNFs face when helping residents assess and plan for their end-of-life care options.

    Below, we outline four barriers to ACP conversations that SNFs face and what to do about them.

    4 ways to overcome ACP conversation barriers

    Challenge 1: Staff discomfort with ACP conversations. ACP conversations can be emotional and even frightening for staff. If staff are uncomfortable with the conversation, the patient may be even more so. The epidemic has accelerated this tension, as stories about Covid-19 victims and the virus' mortality rate fill the news.

    The fix: Provide training and guidance to staff to increase their comfort level with ACP conversations. Read this white paper for resources nurse leaders can use to empower frontline staff to take an active role in connecting patients with hospice care.

    Challenge 2: Lack of staff time. Even in the best of circumstances, SNF staff struggle to find the time to hold these types of conversations. Today, SNF staff time is an even greater concern as many nursing homes face staffing shortages because caregivers are forced to stay to self-quarantine after exposure or isolate after falling ill. 


    The fix: SNFs can consider partnering with organizations that already deliver palliative care services including ACP. Read how Mercy Family Health Center partnered with Sincera—a palliative care and advanced care planning organization to promote ACP conversations. Be certain the organizations plan the mechanism for meeting with all residents and new ones as they arrive.  

    Challenge 3: Revisit existing ACPs given the unique circumstances of the Covid-19 epidemic. Even among patients with documented ACPs, these directives must be re-evaluated. Whether patients have chosen full treatment or to decline CPR or mechanical ventilation for their prior condition or primary disease, such as cancer, their wishes may be different for a situation in which they were to come down with Covid-19. 

    The fix: Organizations can embed safeguards into care protocols to ensure that providers can re-evaluate, understand and comply with advance directives. Read about how to integrate the "resuscitation pause" or the A-B-C-D-E algorithm to ensure that patient wishes are not misinterpreted.

    Challenge 4: Lack of access to family members who would be involved in care planning, due to curtailed visitation. To prevent disease introduction and spread within these facilities, most nursing homes are prohibiting visitors. Yet, advance care planning is an ongoing process that ideally involves multiple conversations among residents, family members, and health care professionals. A clinician needs to determine if the resident has the capacity to make their own decisions and if not, identify who the decision maker is.

    The fix: Connect with families virtually. During this epidemic, HHS has waved HIPAA security rules to make it easier for providers to deliver telehealth services. SNFs can now conduct advance care planning conversations through the phone or videoconferencing. You must have two individuals hear the patient wishes, see it documented, and witness the signature.  Get the digest on how Medicare's telehealth rules have changed to confront Covid-19 and what's required to be reimbursed for ACP conversations.

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