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Implementation of a Facilitated Advance Care Planning Process in an Assisted Living Facility

Hall, Nancy A. DNP, RN; Jenson, Carole E. DNP, RN, ACNS-BC, CCRN

Journal of Hospice & Palliative Nursing: April 2014 - Volume 16 - Issue 2 - p 113–119
doi: 10.1097/NJH.0000000000000033
Feature Articles

Increasing numbers of older Americans with chronic, life-limiting illness are residing in assisted living facilities. Advance care planning can provide for care at the end of life consistent with patient preferences. The purpose of this project was to implement the Respecting Choices model of Provider Orders for Life-Sustaining Treatment (POLST)–type advance care planning in an assisted living facility. POLST–type advance care planning results in a document that communicates care preferences as a provider’s order, actionable in local health care settings. Eight residents and their health care agents participated in POLST-type advance care planning; POLST documents were signed by the physician. Follow-up review of the assisted living medical records indicated that residents who experienced POLST-type advance care planning had more provider orders addressing life-sustaining treatments than were previously present. Ninety-four percent of participants who completed a satisfaction survey rated the overall quality of the discussion as excellent. In the context of a community-wide effort, POLST-type advance care planning was successfully implemented with appropriate residents in an assisted living facility, providing for clearly documented orders to inform end-of-life care consistent with residents’ preferences.

Nancy A. Hall, DNP, RN, is assistant professor of nursing, Bemidji State University, Minnesota.

Carole E. Jenson, DNP, RN, ACNS-BC, CCRN, is assistant professor, Graduate Programs in Nursing, Winona State University, Rochester, Minnesota.

Address correspondence to Nancy A. Hall, DNP, RN, School of Nursing, Bemidji State University, 1500 Birchmont Dr NE, Bemidji, MN, 56601 (

Funding for this project was provided by a grant from Northwest Minnesota Foundation and Sanford Health of Northern Minnesota.

The authors have no conflicts of interest to disclose.

© 2014 by The Hospice and Palliative Nurses Association.