Building upon the evidence-based model created by Gundersen Health System, Honoring Choices brings together three competing health systems - Bon Secours, HCA and VCU - and community organizations with a goal of making advance care planning (ACP) a routine component of every patient's care experience. Through our collaborative the medical team is trained in facilitating value-neutral conversations between patients, their loved ones, and their providers that will allow an individual's goals of care to be honored. This person-centered approach helps individuals to navigate the complex future medical decisions that may need to be carried out by a trusted loved one if the patient is unable to speak for him or herself. The documentation generated from these conversations allow the medical team to deliver the care the patient wants - no less than expected and no more than desired. Knowing that encouraging ACP can help a patient live well, we also see the impact on the patient's loved ones who are equipped to feel confident in their knowledge of the patient's goals of care and the impact on the medical team that is supported in knowing how to best support their patient.
Honoring Choices® Virginia is a collaborative initiative of the Richmond Academy of Medicine Trust, a tax exempt nonprofit organization that serves as an incubator for programs that improve patient care in our community. The mission of Honoring Choices is to encourage advance care planning conversations among individuals, families and health care providers throughout our communities so that individuals’ health care choices are best honored. Honoring Choices Virginia is a partnership of the Richmond Academy of Medicine, Bon Secours Richmond Health System, HCA Virginia and VCU Health. It is governed by the Richmond Academy of Medicine Trust Board of Trustees, which is comprised of past and present RAM leaders, and the Honoring Choices Virginia Advisory Board, which is comprised of community representatives.
Three years ago RAM pulled together 100+ community leaders to have a dialogue about how we could collectively work together to improve the quality of care patients receive at the end of their lives. From that meeting, a common vision was developed, and the Academy and the three health systems evaluated various approaches to helping patients make informed, advance medical decisions. They selected the Respecting Choices model developed by Gundersen Health System, which is now being implemented in communities across the globe. It requires three key elements of its participating partners – (1) system redesign; (2) education and facilitator certification; and (3) community engagement. For community engagement, partners are encouraged to reach out to their community with common, consistent and repetitive messages; further, partners should develop unique strategies to meet the needs of special population groups.
What does it look like when advance care planning goes the way it should?
A patient, we’ll call him Mr. Smith, was experiencing stroke symptoms and drove himself to the ED. Upon admission, he stated he did not have family or an advance medical directive. After receiving an invitation to talk more about what care he would want if he could no longer speak for himself, Mr. Smith agreed to have a conversation that resulted in choosing a close friend to serve as his surrogate decision-maker. Mr. Smith’s friend joined him and an advance care planning facilitator in a discussion about what quality of life meant to him, resulting in completion of an advance directive, and the friend affirmed his willingness to honor Mr. Smith’s care decisions. Sadly, some time after his discharge Mr. Smith suffered a cardiac arrest and was brought into the hospital in a vegetative state. Using the advance directive and what he learned in the conversation with his friend, the health care agent was able to make the decision to withdraw support per the patient’s wishes.
How would this case have gone if there had not been an advance care planning conversation? Anecdotally we hear that a majority of hospital ethics cases involve some layer of advance medical decision-making that didn’t go as it should – there is no advance directive on file, a next of kin cannot be identified, a health care agent is unsure of what the patient would want. These cases cause delays in critical medical decision-making and significant distress for the grieving family and for the health care team caring for the patient.
Two years ago the Honoring Choices® Virginia collaborative launched its first nine clinical sites; today, we are live in 37 clinics, in-patient units and home care programs across the three participating health systems – Bon Secours Richmond, HCA Virginia and VCU Health. Our clinical leadership meet on a bi-weekly basis to ensure the program is consistently implemented across the care settings (allowing for customization to fit practice workflow and individual strengths) and to address community-wide barriers such as difficulties in sharing information across systems. We believe we are a first-of-its-kind community-wide collaborative in this region and that we are demonstrating every day the impact our health care partners can make when we collaborate to address the needs of our citizens.
Nearly 150 facilitators are available to make sure our community members have the opportunity to have the types of conversations that would allow, in the event of crisis, their medical team to honor their advance health care decisions. They are working to normalize these conversations as a routine aspect of the care experience, so that individuals from age 18 to 108 can thoughtfully consider what medical decisions they would want a surrogate to make for them in the event they cannot speak for themselves.
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