Advance Care Planning Series

For Nursing Home Care Facilities


Advance Care Planning – Introduction

Establishing goals of care helps team members align the types of care a resident receives to the care they want. The process of discussing these goals and decisions is called Advance Care Planning, or ACP.

3 Takeaways for NH Staff:

  • Resident goals of care include both simple things (like food preferences) and complex things (like whether or not to go to the hospital).
  • When ACP decisions are written down, they become part of the resident’s Advance Directive.
  • ACP includes identification and designation of a resident’s health care representative.

Comfort Measures

Comfort measures can be defined as understanding someone’s condition and deciding to focus on enhancing the quality of life remaining for the resident. Comfort measures are about adding care, not taking it away.

3 Takeaways for NH Staff:

  • Providing comfort measures does not mean “giving up” on a resident.
  • Comfort measures focus on quality of life rather than measures intended to sustain life.
  • Residents and families should understand what to expect as their condition advances.

The Truth About CPR

Though the general public has heard of CPR or knows what CPR stands for, it is widely misunderstood when it comes to use of CPR with residents of long term care facilities. Much of the confusion about CPR is due to how it is portrayed on TV.

3 Takeaways for NH Staff:

  • CPR is only effective approximately 3% of the time when performed in the long term care setting.
  • If no resident decision is documented, a resident will be a Full Code order by default.
  • Full Code will require full treatment, including ICU and ventilator support.

Palliative Care

Palliative care is healthcare that focuses on managing the discomfort, symptoms and stress that is related to chronic conditions and serious illnesses. The goal of palliative care is to balance quality of life as well as prolonging life for the resident to the extent possible.

3 Takeaways for NH Staff:

  • Palliative care is supportive care that should be provided to both the residents and their families.
  • Palliative care includes symptom management and spiritual support.
  • Choosing palliative care does not mean disease-directed treatment stops.

When There Is A Change In Condition

A resident’s Advance Directives should be referred to whenever a change in condition occurs. This is also a time when staff should speak with the resident or representative to ensure the documented goals of care are up-to-date.

3 Takeaways for NH Staff:

  • Have open communication with the resident and their family during a resident’s change in condition.
  • Be sure the provider knows the resident’s goals of care.
  • Communicate goals of care with the hospital if there is a transfer.


Gilissen J, Pivodic L, Wendrich-van Dael A, Gastmans C, Vander Stichele R, Van Humbeeck L, Deliens L, Van den Block L. Implementing advance care planning in routine nursing home care: The development of the theory-based ACP+ program. PLoS One. 2019 Oct 17;14(10):e0223586. doi: 10.1371/journal.pone.0223586. PMID: 31622389; PMCID: PMC6797173.

Wendrich-van Dael A, Gilissen J, Van Humbeeck L, Deliens L, Vander Stichele R, Gastmans C, Pivodic L, Van den Block L. Advance care planning in nursing homes: new conversation and documentation tools. BMJ Support Palliat Care. 2021 Sep;11(3):312-317. doi: 10.1136/bmjspcare-2021-003008. Epub 2021 Jun 23. PMID: 34162581; PMCID: PMC8380900.

Have questions? We are here to help.