Advance Care Planning is an ongoing planning process for future care and treatment decisions. It is often undertaken with a view to potential future times when the client may no longer be able to make his/her wishes known. Baycrest lacked a formalized policy on Advance Care Planning (ACP). Therefore, there was no effective and efficient system-wide process for discussing, determining, documenting and reviewing the expressed wishes of our clients.

The Baycrest Advance Care Planning Working Group undertook a three year initiative that identified the gaps in the ACP process and developed effective and efficient solutions to ensure that, whenever possible, future care and treatment decisions respect the values and wishes of the client. The ACP policy was developed along with an introductory pamphlet about ACP, a Conversation Guide on ACP for clients (which entails the creation of an Advance Care Plan), and a form that documents the “Plan for Life-Sustaining Treatment” (PLST) options, to capture the future wishes and treatment orders of our clients. Educational materials and tools were developed and staff received education on these tools in the three pilot areas of the organization, including two long-term hospital units and two residential care units in the Apotex, Jewish Home for the Aged Long Term Care Home. Finally, an evaluation of the trial was conducted through implementation of focus groups, surveys and several one on one interviews.

Through our process we needed to be mindful of the differential laws existing in Ontario (for example the Long-Term Care Home Act, The Substitute Decision-Makers Act, The Mental Health Act), and engaged a lawyer to ensure that our processes and tools were aligned with the requirements set out in each act.

Our project demonstrates both innovation and creativity in how we created toolkits in order to be more inclusive of a greater range of the aging population. Our policy and tools are applicable not only with capable individuals, but also with individuals who are identified as being incapable. Our toolkit has empowered substitute decision-makers who act on behalf of individuals identified as incapable.

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Title: Professional Practice Chief of Social Work

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