Advance Care Planning Tool



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RPA Advance Care Planning Tool

RPA developed this tool to facilitate advance care planning for CKD and ESRD patients. It should be kept in the patient’s paper or electronic chart. RPA urges nephrology practitioners to address advance care planning within the first 90 days of providing care, and to review these care plans annually or more frequently, particularly if a change in patient

status occurs. RPA advises that there are a variety of resources available that may assist in the individualization of the advance care planning process, including the second edition of the RPA Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. The specific resources referenced below are only examples of some of the validated evidence-based tools currently in use for CKD or ESRD patients.

RPA strongly endorses the role of nephrology practitioners in conducting timely, consistent, detailed, and ongoing discussions regarding advance care planning for all CKD and ESRD patients as part of a patient-centered approach to nephrology care.

|Patient Name |Practitioner Name |Notes |

| | | |

|Advance Care Planning Item | | |

|Assessment of patient’s overall condition including estimate of prognosis | | |

|(consider referring to calculators/sq or other similar tool; this | | |

|tool is only applicable to hemodialysis patients) | | |

|Assessment for cognitive impairment (consider MOCA test, ) | | |

| | | |

|Determination of decision-making capacity | | |

| | | |

|Identification of a medical decision-maker in the event of incapacity (called | | |

|durable power of attorney for health care, medical power of attorney, health care| | |

|agent or proxy, or surrogate depending on the state). | | |

|Determination of advance directive status. (for state-specific advance | | |

|directives, see i4a/pages/index.cfm?pageid=3289) | | |

| | | |

|Determination of preferences regarding cardiopulmonary resuscitation | | |

| | | |

|Determination of other desired treatment limitations (e.g., do not intubate, no | | |

|vasopressors, no feeding tube, no transfer to higher level of care, etc.) | | |

|including circumstances under which patient would not want to start or would want| | |

|to discontinue dialysis, if applicable under state law. | | |

|Completion of Physician Orders for Life-Sustaining Treatment (POLST) (or similar)| | |

|medical order form if available and applicable under state law | | |

|Interdisciplinary family meeting regarding patient's preferences and goals for | | |

|treatment | | |

| | | |

Questions regarding this tool may be directed to Robert Blaser, RPA’s Director of Public Policy, at 301-468-3515, or by email at rblaser@.

April 2012

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