Advanced Care Plan: Case Study and Implementation for Anthony Vella

This assignment provides a detailed analysis of an advanced care plan (ACP) for a 46-year-old man, Anthony Vella, diagnosed with stage 4 pancreatic cancer. It explores the crucial steps involved in initiating and implementing an ACP, including the introduction of ACP discussions with the patient and family, emphasizing the importance of early intervention and preparation. The essay outlines the necessary preparation for these discussions, the key participants involved (patient, family, and healthcare team), and the essential informational data required for creating a comprehensive ACP. The assignment highlights the significance of regular reviews and amendments to the ACP over time, concluding with a discussion on the activation period of the ACP program. The essay emphasizes the importance of patient-centered care and the role of ACP in ensuring that the patient's wishes are respected and followed throughout their end-of-life journey, drawing on research and principles from healthcare improvement initiatives and relevant studies.

Running head: ADVANCED CARE PLAN
Advanced Care Plan
Name of the Student
Name of the University
Author note

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This assignment is focused on the case study representing the condition of 46 years old
man named Anthony Vella who had been suffering with stage 4 of pancreatic cancer which had
been diagnosed six months back after he was presented to emergency department with acute
abdominal pain. Anthony had been wedded to Luisa for 20 years; and the couple are blessed with
two children, both aged 16 and 19 respectively.
The rest of this assignment emphasizes on the procedure of defining and curating an
advanced care plan (ACP) that is generally implemented in such cases, like that of James Smith.
As per the design of this assignment, the first course of action is centered on discussing how a
conversation session with the patient and the respective family members about crafting an ACP
can be introduced and implemented. For any strategy to be successfully implemented it is
extremely important to design the strategy carefully, however the very next step that is extremely
necessary is the preparation that goes behind the implementation procedure. Hence, in this case
as well, the strategizing step was followed by explaining the preparation required for that
discussion process. The following section after the preparation procedure discusses the members
that should participate in the said ACP discussion, followed swiftly by an elucidation of the
necessary informational data needed in devising such a plan. Now, ACP can be defined as the
document that has the potential to change over the lifespan of a particular individual, the next
requirement is periodic reviewing and amending the ACP; the next section discusses the time
limit after which the ACP must be reviewed and amended. The final section of this assignment
discusses the activation period of the ACP program as well. Finally, the conclusion of the essay
briefly concludes the primary points presented in the entire assignment.

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Introducing the Advanced Care Discussion
The importance form of the impetus for the development of the ACP derives from the
fact that one out of four people dies in the United States that effectively occurs in the nursing
homes and also 70% cases are been encountered in the hospitals.
However, little has been observed in the early 1990s, that the statistics have reported that as
many as the residents of the nursing home care have been receiving the end of the care of the life
that was not in the compliance to the previous patients that have expressed the wishes in the
advanced form of directives. In the part that are due to these form of issues, the Institute for
Healthcare Improvements that are been producing the set of the principles that have been
defining the responsibility of the health care professionals providing care that are holding the
ACP form of discussions with the patients. There are five principles, that are represented in
Figure 1, offer a framework for designing effective inter- conversation with patients (Adams,
Kabcenel, Little, &Sokol-Hessner, 2015).
Figure 1. Five principles of being conversation ready (Adams et al., 2015).
Connect
Exemplify
Engage Steward Respect

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As opined by Adams et al. (2015) in his article, the key strategy instructs the health care
professionals to be engaged with the patients and their families so that they can easily determine
what care components in the most necessary to them. The model associated with this process
instructs the health care providers to be connected with the families of the patients more
compassionately and finally connects it with the patients in a specific way that are culturally and
also individually been respectful.
Various studies have observed that the home residents with respect to the discussions of
the ACP have been found out that too often the discussions also takes place at the time of the
admissions that if it occurs at all. In a particular form of situation, there needs to be systematic
form of the reviews that are needed to be formed for the four specific studies of the ACP that
have focused on the residents of the nursing home and they were found admitting, the healthcare
staff often realized that the patients that were incapable for having for having the discussion at
the time of their admission. However, it has to be understood that when dementia occurs the
cognitive functioning power of the brain is more likely to be compromised, having the ACP
conversation prior rather than later had always been a vital issue to ascertain enhanced quality of
life.
In the case represented in the assignment of James Smith, these principles or ideologies
would initially mean discovering circumstances to connect with Mr. Smith along with his family
regarding his EOL care needs. As the cancer care team designated to him had indicated two
weeks prior that no additional treatment, except end of life care, would be efficient, the complete

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newest time for this conversation should actually be at that time. However, the survival rate of
stage IV pancreatic cancer is only a window of five years time (ACS) (American Cancer Society,
2016). As per the condition that the patient under consideration is in the life expectancy for the
patient is not more than five years, hence the ACP talk preferably been held immediately after
diagnosis, in case that Mr. Smith had not arranged an ACP or AD in advance.
The early ACP discussion just after the cancer diagnosis will increase the likelihood of
the patient engaging in design and implementation of a patient centered ACP (Der Schmitten,
Lex, Mellert, Rothärmel, Wegscheider & Marckmann, 2014; Houben, Spruit, Groenen,
Wouters& Janssen, 2014). Additionally, it also needs to be considered that the AD documents
that are completed after a successful ACP discussion are extremely beneficial for the traetmentv
plan to follow, studies suggest that thes4e documents not provides relevant data regarding the
severity of the patient as compared to the data collected without a valid ACP discussion with the
patient (Der Schmitten et al., 2014; Garrido, Idler, Leventhal& Carr, 2012). Another fact can be
considerd completing both the documentation, AD along with ACP, considerably enhances the
possibility of patient preferences being valued and complied along with being tended so that that
care that complies with the preferred care requirements is provided (Brinkman-Stoppelenburg,
Rietjens& van der Heide, 2014; Houben, Spruit, Groenen, Wouters, & Janssen, 2014).
Preparation for the Advanced Care Discussion
Adams et al. (2015) opined an imperative assortment of different steps that can be
implemented by a healthcare providing organization to arrange and carry out ACP discussions
with patients along with their family members. Although, the steps are not completely
characterized still, utilizing the five different principles represented in the Figure 1 the IHI that
characterizes main steps in planning to carry out these discussions. As per the findings of Adams

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et al. (2015), the initial phase of organization is to employ the connect population to care
planning procedure so that they can interpret the number of patients that have already been
selected a healthcare proxy, the number that have successfully documented their “what matters”
issues, and of those without either or both of those documents, how many of them were asked to
contemplate those issues. The stewardship part of the entire preparation cycle comprises of
documenting the data from healthcare proxy and “what matters” concerns within the records of
the patients (Adams et al., 2015). The concept of exemplify principles indicate at exploring the
exact figure of the health care workforce that have on their own discussed about ACP with their
own families, and recorded their ACP and the “what matters” wishes along with having a
advanced healthcare proxy that is recorded (Adams et al., 2015). The majorly difficult aspect of
the entire preparation procedure is crafting a strategy that can employ the spiritual, philosophical,
and cultural beliefs of patients even if those beliefs are potentially quite dissimilar from
healthcare staff (Adams et al., 2015).
In case of Mr. Smith, there had been no data provided that discusses his spiritual or
cultural setting, neither were any recorded documentation about his “what matters” wishes; the
patient even lacked a legal healthcare proxy to take clinical decisions in behalf of him in times he
was incapable of response.
Participants of the Advanced Care Discussion
The ACP conversation can engage a varied amount of several healthcare givers.
However, it must necessarily include the patient his family members. With respect to Mr. Smith,
the ACP discussion procedure should also have included one or more individuals belonging to
the cancer care team he was assigned, it is not mandatory for the oncologist to be included, but
someone skilled to carry out ACP discussions (Adams et al., 2015). In case the ACP discussion

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have not been carried out as an element of the cancer treatment plan he was designated, as
suggested by the ACS, the primary instance he had been taken to the health care facility, a
specialist must have had ACP conversation with Mr. Smith and the members of his family
(American Cancer Society, 2016). Given that he had been pursued by the emergency department
it can be interpreted that the patient had been in a critical condition, hence, it can be concluded
that having the ACP discussion with the patient much earlier would have been far better. Now in
case none of the above healthcare professionals discussed ACP with the patient, it would be
extremely necessary for initiating the discussion by the primary physician.
Information of Advanced Care Plan
The main difference between the ACP document and a DNR (Do Not Resuscitate) is that
the information provided by ACP documents is much more inclusive than the latter. The
recommendations of the IHI indicate that an ACP must initiate with recording the answer given
by the patient to “What matters to you?” (Adams et al., 2015). The questions belonging to this
genre reveal the aspects of life that are most central to the patient and put in largely to the quality
of their life. Furthermore, the ACP is also known to typically include a living will that describes
the types of treatment procedures the patient wishes to undergo, along with providing a strong
power of attorney which nominates some other individual to take the medical decisions on behalf
of the patient in times when he or she is not capable of making those decisions on his own, and
documents choices for organ and tissue donation, durable healthcare power of attorney, and
religion documentation, cultural, or interpersonal for procedures like dialysis or cardiopulmonary
resuscitation (CPR) (National Institute on Aging, 2016).
McMahan, Knight, Fried, and Sudore (2013) researched the factors that the patient
families and the patients themselves felt were most important in preparing an ACP. The

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suggestions from the particular study incorporated typical AD forms, but at the same time
identifying and documenting the factors that were deemed as most crucial, ensuring the care
proxy designated for the patient (the person particular in the durable power of attorney)
understood their role in clarity, determining whether flexibility should be allowed to the
surrogates in decisiveness or adhere strictly to preferences that the patient has previously
expressed which helped in the family member or friends knowing the patient’s wishes
(McMahan et al., 2013).
A chief aspect in this context is to ensure ACP being safely documented in a manner that
can be effortlessly understood, for the patients that are not very fluent with English or those who
do not understand legal terminologies; the ACP documents ensures that everyone associated with
the patient and the treatment procedure selected for him is equally involved, from family and
friends of the patient to healthcare providers, everyone is clear about wants and needs of the
patient. Robinson et al. (2013) distinguished that healthcare providers frequently discover ACP
plans are very critical to incorporate into a clinical setting due to the concerns of
complicatedness in making the legal documentation comprehensible, concerns with ambiguity in
the legal background of the different documents, and concerns with differences between patient
preferences eventually (Robinson et al., 2013).
For Mr. Vella, his ACP comprises of a strong power for the attorney for allowing his wife
and the other members of the family for making the decisions of this healthcare when he was
very much incapable for doing so. Moreover, it should the core responsibility of his wife to give
his proxy, should have been aware of all her responsibilities, and should know about Mr.Vella’s
have expressed their form of needs in the care plan. Since he had not been responding when he
was admitted to the health care facility in the last event, he was also incapable to make

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healthcare decisions on his own regarding his conditions. Furthermore, a DNR would have
potentially avoided extreme measures required otherwise to revive him, and organ and tissue
donation forms serve as the means to permit his needs related to those issues are respected.
Reviewing the Advanced Care Plan
According to the recent studies, the perception of the cancer patients regarding the ACP
is a very dynamic one, the cancer patients often find is to be a potent device rather than being a
permanent decision that is made only at one time. Michael et al. (2013) discussed the nature of
response that the cancer patients have shown to ACPs over the course of their diseases. The
patients who are suffering from cancer has been often found out that the ACP is a very dynamic
form of the instruments rather than the fixed form of decisions that are been fixed form of
decisions over the course of the disease. American patients with the incurable form of the
pancreatic cancer like Mr. Velle, it has been observed in their medical reports shows only about
fifteen percent of the times. Moreover, the DNR orders have also shown that the cancer patients
are overpoweringly signed after the day that the patients died, either by the patients or by the
proxies belonging to the healthcare systems. In one of the study by the Australian cancer
patients, discovered that the extent of awareness in the public and utilization of different
components of ACP (like living will, DNR orders, and more) varied extensively amongst
different participants, along with the fact ACPs were tremendously changeable to cancer
patients, that were unusually sought to judge various aspects of ACPs during various phases in
their disease procedure. The most evocative declaration that the participants made had been that
the ACP was “an iterative process” (Michael et al., 2013, p. 2198).

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With respect to the case represented by Mr. Vella, the ACP discussions it ought to be at a
minimal form of level that are needed to be addressed at the time of the initial form of the
diagnosis of the cancer, if it is not done before. As every stage of the protocol of his treatment
was concluding, the plan has never been revisited for ensuring that Mr. Vella’s desires were also
with accordance to the alignment with the plan. This form of literative form of process ensures
that Mr. Vella wishes were documented and updated with accordance to his physiological health
and his process of the disease have also altered.
Activating the Advanced Care Plan
The commencement procedure of ACP program is actually established on the specific
situation of the patient. It has been observed that in cases when the ACP is designed and
characterized by Michael et al. (2013), the commencement of the ACP plan that may take place
for the over the longer period or the from time to time. For instances, to have a proxy refers to
the fact that when the patient becomes incompetent and looses the capacity of making the
healthcare decisions, they designated form of the proxy becomes ultimate for the patients. A
circumstance where a patient is incapacitated for a short period of time which can lead to an
ACP being initiated in advance until the patient can make clinical decisions on their own. Adams
et al. (2015) in his article has suggested that if the entire healthcare industry propagates towards
achieving the five conversation-ready principles, which are considered to be fitting stewards of
the patient wishes, ACPs in most cases can be efficient and dependable for all kinds of patients.
For Mr. Vella, the ACP was supposed to be performed at the time he was initially taken to the
emergency department and had been unable to communicate his desires or preferences regarding
his healthcare.

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Conclusion
The above paper addresses the issue for the advancing care planning for the patients in
the context of Mr. Anthony Vella, the cancer patient suffering with the Stage 4 of pancreatic
cancer. The situation that Mr. Vella had been in highlighted the significance of preparing for the
carrying out the conversation about the ACP much earlier than the disease left the patient had not
been responding. The instrumental structure of elements of ACP that incorporated a living will,
ADs concerning patient desires for activities to be carried out on him, choices for organ and
tissue donation, durable healthcare power of attorney, and religion documentation, cultural, or
interpersonal for procedures like dialysis. The ACP plans here are nothing but appropriate
iterative procedures instead of being a one-time permanent set of main decisions, along with that
are accurately performed earlier in the course of diagnosis and treatment, the moment a
potentially severe or grave condition is diagnosed and during disease progression.
Commencement of the ACP happens each time the patient’s situation requires major measures
being contemplated.

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References
Adams, K. M, Kabcenel, A., Little, K. &Sokol-Hessner, L. (2015). “Conversation ready”: A
framework for improving end-of-life care. IHI White Paper, Cambridge, MA: Institute
for Healthcare Improvement. Available from: http://ihi.org
American Cancer Society (ACS).(2016). Pancreatic survival rates, by stage.American Cancer
Society.Available from http://www.cancer.org
Brinkman-Stoppelenburg, A., Rietjens, J. A. C. & van der Heide, A. (2014). The effects of
advance care planning on end-of-life care: A systematic review. Palliative Medicine,
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Der Schmitten, J. I., Lex, K., Mellert, C., Rothärmel, S., Wegscheider, K., &Marckmann, G.
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