On-going quality improvement work at William Osler Health System has been done to addresses a specific quality of care problem: the fact that some long term care (LTC) residents are transferred to hospital, sometimes at end of life, because of consent related errors (i.e. failure to respect wishes not to be transferred; advance directives being interpreted as consent for treatment; or advance directives being completed by substitute decision-makers (SDM)). A 2012 assessment, showed these errors contributed to transfers that resulted in residents receiving treatment they did not want or that was of no benefit to them, (i.e. Residents undergoing unwanted amputations just prior to death, residents being tube fed despite wishes to forgo artificial nutrition.) Eliminating these errors is obviously important to improving quality of care and patient safety.

Through root cause analysis cycles we identified the "Level of Care” (LOC) form as the key driver promoting error based transfers. This form is used in 628 LTC homes throughout Ontario, representing 77,600 LTC beds across the province. The elimination of this form is necessary to decrease error based transfers.

In collaboration with Central West LHIN, LTC homes, and numerous Plan Do Study Act (PDSA) cycles, we designed a new tool called an "Individualized Summary" (IS). This one page tool promotes decision making that is aligned with the provincial consent legislation and clarifies:  (1) the current treatment plan, and (2) instructions for obtaining consent when there is a change in condition, and (3) ensures the documentation of the resident’s wishes, values, and beliefs, and any advance care planning requests.  The form, which is completed on admission, is updated as needed (for example, when the treatment plans change, or when the resident has new or different wishes to share).

Clients have been an important part of informing the development of the IS through rapid cycle feedback from person’s involved in the early development of the form. Client’s found discussing their wishes, sometimes for the first time, very valuable and were empowered when finally understanding their role in decision-making at end of life. Once the Individualized Summary is in place, the individual patient’s wishes, values, and beliefs remain ever-present during consent-related discussions, even if that patient becomes incapable and no longer able to consent on his or her own behalf. The Individualized Summary is aligned with Ontario’s Health Care Consent Act; therefore the documented information is relevant at all health care facilities within the province of Ontario.

The Individualized Summary promotes informed consent which healthcare professionals caring for residents in Long Term Care are legally and morally obligated to obtain. This practice provides the basis for an important change in culture in the provision of treatment / transfers in LTC and sets the conceptual framework for on-going team member role clarity by preventing error based transfer caused by problematic “Level of Care” forms and also by dramatically affecting the culture of end-of-life decision-making.

Contact Information:

Title: Community Ethicist

Contact email: Jill.Oliver@williamoslerhs.ca

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