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Table 5 The guideline of ACP care model

From: Action research study on advance care planning for residents and their families in the long-term care facility

1. Opening the conversation with the interview guidelines about the life story of residents

1–1 With residents

• Open the conversation with the interview guidelines known as “Life is Like the Seasons.”

1–2 With families

• Open the conversation with the interview guidelines entitled “Memories of my Dad/Mom/Grandma/Grandpa/Sibling.”

2. Continuing life stories to the quality of remaining years of the residents

2–1 With residents

• When residents mentioned that they moved to the facility because of poor health, questions could be raised regarding the influence of their illness on their current quality of life and expectations for their future life.

2–2 With families

• When families disclosed heir reason for sending elderly residents to the facility and their expectations for facility care, explanations could be provided regarding the resident’s current health conditions and expectations for their future life.

3. Gradually changing the topic to the EOL care issues

3–1 With residents

• When residents mentioned their desire to experience a good death, topics related to EOL care could be discussed.

3–2 With families

• Inform families of resident’s decisions regarding EOL care and the reason why they did not discuss this topic with their families.

• When family members expressed interest in EOL care options, topics related to EOL care could be discussed.

4. Concluding the conversation by explaining the content of ADs and hospice care

4–1 With residents

• Introduce ADs and hospice care from the “good death” perspective.

• Explain the relationships among ADs, hospice care, and a good death.

• Explain the role of ADs, hospice care, and their contents.

• Explain the significance of signing up from the cultural perspectives of Confucianism, Taoism, and Buddhism:

- Signing of ADs in advance is the only effective means of fulfilling the goal of naturally experiencing a good death, as advocated by ancient people.

- The circumstances in which people die have nothing to do with fate or reincarnation. The signing of ADs in advance is most crucial.

- Signing of ADs in advance is a means of reducing the sense of guilt and conflict in the family.

• Allow time for elderly residents to ask questions and ensure that they understand the meaning of signing ADs, accepting hospice care, and their perspectives on experiencing a good death.

 

• If necessary, assist residents in the signing of ADs.

4–2 With families

• Explain and ensure family understanding of ADs and hospice care-related topics such as the ACP process, the content of ADs, and the correlation between hospice care and a good death.

• Have the medical team set up short-term, mid-term, and long-term care targets with families based on the health conditions of residents.