Development, implementation and evaluation of a transmural care pathway advance care planning

Background: Preferences regarding care and treatment now and in the future for older people are often unknown and not exchanged between care settings and health care professionals. This leads to not dying at the preferred place, increased symptom burden and impacts quality of life and dying. Approach: Together with all people involved in advance care planning, from different disciplines and care settings, we developed a transmural care pathway advance care planning, with work instructions, clear roles and responsibilities and one format advance care planning. Disciplines involved are mainly nurses and physicians from both primary care, nursing homes and hospitals. Furthermore older people and informal caregivers participated in the complete process of development, implementation and evaluation. We tested the transmural care pathway advance care planning, with work instructions and one format advance care planning in a pilot study, including a digital exchange platform between disciplines and care settings. Results: The format and work instructions are feasible according to participants. The possibility to digital exchange information was very much appreciated, however included some barriers. Double registration was still necessary and district nurses were not able to participate because of regulation barriers in registration. These barriers need to be solved to optimal implement transmural advance care planning including digital exchange. Implications:On a national level we are now connected with the initiatives to develop and implement the digital exchange of advance care planning. On a regional level we started with implementation and evaluation of the format and care pathway including instructions in one home care organization with district nurses. Part of the implementation is a training of district nurses on advance care planning. We will evaluate the implementation on multiple levels and outcomes (eg symptom burden, health care use, place of death and a process evaluation). These results wil be used for further implemenation and evaluation of transmurale advance care planning on a regional level

Advance care planning · Care pathway · End-of-life care · Health care · Integrated care · Process (computing · Quality (philosophy · Work (physics · Family and Patient Care in Intensive Care Units · Frailty in Older Adults · Palliative Care and End-of-Life Issues