Ask OPPORTUNITIES

Share
Early and ongoing Understand and continually
• Serious Illness Conversation guides and tools
conversations communicate wishes
• “Surprise question” trigger
• Advance Care Planning tools

OPPORTUNITIES
• Culturally sensitive conversations
“Conversations “We needed information about
are critical, but • Embedding ACP into person-centered care approach
what to expect, what our choices
consider the extra were and what was available
paperwork burden on sooner rather than half-way
frontline staff.” through or at the end.”
“It is so important that
GAPS “Knowing what my sister
staff can differentiate
wanted was important. As
between their beliefs and
• Lack of SKILLS, proficiency and time much as we didn’t want to
the client’s wishes.”
talk about it, we needed to.”
• Not clear who to involve in CONVERSATIONS “We knew what we
wanted, but we didn’t know
• Limited understanding about DISEASE TRAJECTORY how to make everyone

ge
and end-of-life prognosis else know.”

le d
“They listened to me.

Sk
i ll s
They understood–I

ow
GAPS knew what my husband

Kn
Advance Care wanted. If they didn’t
CHANGES in patients’ wishes not shared
Planning • understand, they asked.
We all agreed.”
• Varied ACCESS and USE of tools and documentation
(ACP)
• Lack of SHARING between care settings and providers

Respond Processes

Reflect decisions in care OPPORTUNITIES

INCLUSION OF ADVANCE CARE PLANS INTO CARE DELIVERY
plans and legal papers • Communities of practice
• Palliative care teams and networks programs Advance care planning is an ongoing process of making decisions about the care
• Collaborative assess, treat & refer process individuals want to receive if they become unable to speak for themselves.

This Experience Map is a visual representation of opportunities and gaps

shared by subject matter experts, patients and caregivers in translating
advance care wishes into the planning and delivery of home care.
“My sister’s ACP was simple—she Experiences were identified through a stakeholder workshop,
wanted to be at home with her telephone interviews and online surveys. Input was validated
family around her—not in hospital, “It is not just physical
not in a swirl of chaos in an needs. It’s also strategies to through an E-Delphi survey with a panel of experts.
emergency department.” preserve my dignity, quality
GAPS of life and a plan to meet my
spiritual needs – this is often
• Minimal ACCOUNTABILITY and tracking systems neglected.”
“The plan was
• Varied understanding of LEGAL and ETHICAL obligations well thought out and in
theory was a good plan. The Building Operational Excellence
• Lack of PROCESSES to include decisions into care planning execution and delivery on Home-Based Palliative Care
the plan were what
fell short.”
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