Happy Birthday

 We met over 50 years ago, and over time we have spent some good times and some sad times together. Because of you and your influence, I have, over time, become a better version of myself, than I would have been on my own. I owe you my life and my love. Happy Birthday and my wish is for many more with you.

Housing Options for Seniors

 A great resource for those who are retiring and are thinking of changing where they live is a resource called the Housing Options for Seniors. This publication was produced by the National Association of Area Agencies on Aging and written by Holly Robinson, Associate Staff Director at the American Bar Association Commission on Law and Aging. AARP also supported this project by participating in the review process and with printing and distribution support.

What I like about this report is that not only does it review the various options it lists a series of questions to help a person move toward a decision. 

For example, the following questions are for those considering the housing options covered in this booklet, it is important that they ask themselves these general questions:

·        What kind of lifestyle do I want?

§  What will my living conditions be like?

·        How important is my choice of location?

§   How close would I like to be to family and friends, doctors, pharmacies, other medical facilities, shopping, senior centers, religious facilities, and other amenities?

·        Does my current health status require that I look for features that will help me move about more comfortably?

·        How much will the housing option cost?

·        What, if any, in-home support services will I receive for my money?

·        Am I eligible for any publicly funded or subsidized services, such as Medicare or Medicaid?

·        What in-home support services are available now, and in the future, to meet my health and social needs?

·        Have I involved family members and friends in my decision-making, as appropriate?

·        What role will others have in making these decisions?

·        Would it be advisable for me to talk with an attorney so that I understand my rights and any legal concerns?

The booklet also offers resources

Key Resources

■ Eldercare Locator 800.677.1116 www.eldercare.gov

The Eldercare Locator is the first step to finding resources for older adults in any U.S. community and a free service of the U.S. Administration on Aging.

■ American Bar Association Commission on Law and Aging 202.662.8690 www.abanet.org/aging/resources/statemap.shtml

The Commission is dedicated to strengthening and securing the legal rights, dignity, autonomy, quality of life and quality of care of elders

Twinkl

 Are you still teaching or learning English as a second language with old-school methods? Want some fun resources to activate your mind? This group has over 12K members and I hope it continues to grow, I recommend Twinkl Resources for ESL Teachers, speakers of English, English Teachers and English learners.

Many years ago, I had the opportunity to teach an English Second Language (ESL) class to a group of students in high school. I was told before I took the assignment that the previous teacher had laid out the semester and that all I had to do was follow her plans.

That information turned out not to be correct. I started the class and found there were no lesson plans, no records, and no information about what the students needed or where they were in learning the language. All I knew was that at the end of the term, the students would be given a proficiency exam which would determine if they moved ahead or stayed where they were for another year. 

I am a good researcher, but it took me about two weeks to figure out what I needed to do and then I had to find resources to use. It was not easy and back then there were not a lot of great resources. Today English as a Second Language Teachers have many more choices than I did. I maintain a passing interest and I came across a fantastic resource on Facebook called Twinkl Resources for ESL Teachers. 

They have over 655,000 resources for teachers, they offer many of them for free. In addition, they offer help if you have a question or are looking for specific help. The videos they put up on Facebook are original, funny, and accurate. I wish I had access to this resource when I was teaching ESL. If you are an English teacher, or an English user, or an ESL teacher or a learner of English, there is something here for you. 

As I said her site is original and filled with humour, and I highly recommend this site to you. Here are three ways to contact the site, via Facebook at https://www.facebook.com/TwinklESL go to the site https://www.twinkl.ca/ directly or you can join the group at https://www.facebook.com/groups/TwinklTEFLGroup/?utm_source=facebook&utm_medium=socialcial

Advanced Care Planning an alternative view

 Advance care planning (ACP) is one of the things we talk about in our workshops on Personal Planning. We as an organization and I as an individual hold the assumption that ACP will result in goal-concordant end-of-life care. I was surprised to read the following article What’s Wrong With Advance Care Planning? Written by R. Sean Morrison, MD; Diane E. Meier, MD; Robert M. Arnold, MD and published by JAMA. Published online October 8, 2021.

However, the scientific data do not support this assumption. ACP does not improve end-of-life care, nor does its documentation serve as a reliable and valid quality indicator of an end-of-life discussion.

What Is ACP?

The purpose of ACP is to ensure goal-concordant care near the end of life for patients who lack decisional capacity. It is a process to support adults in understanding and sharing their values, goals, and preferences regarding future potential medical care decisions; choosing and preparing a trusted person(s) to make medical decisions; and documenting these wishes so that they can be acted on when future medical decisions need to be made. Most approaches to ACP encourage all adults to participate in the process regardless of their health status. Advance care planning is distinct from “in-the-moment” decision making, in which seriously ill patients and their families engage with their clinicians in goals of care and treatment discussions at present and regarding their current situation.

If ACP led to higher-quality care at the end of life, it would make sense to continue efforts to promote it and integrate it into value-based care. However, a substantial body of high-quality evidence now exists demonstrating that ACP fails to improve end-of-life care. A 2018 review of 80 systematic reviews (including 1600 original articles)1 found no evidence that ACP was associated with influencing medical decision making at the end of life, enhancing the likelihood of goal-concordant care, or improving patients’ or families’ perceptions of the quality of care received. A 2020 scoping review2 that included 62 recent high-quality articles also demonstrated no link between ACP and occurrence of goal-concordant care or patient quality of life. Additionally, these reviews found no association of ACP with subsequent health care use, including emergency department visits, hospitalizations, and critical care. Subsequently, 5 large multisite randomized clinical trials that enrolled patients with cancer (1117 patients at 23 hospital cancer centers),3 nursing home residents (12 479 residents from 360 nursing homes),4 older adults in primary care (759 patients from 8 primary care practices),5 adults with serious illness (515 patients from 20 outpatient clinics),6 and patients with heart failure (282 patients from 2 heart failure centers)7 could not identify meaningful differences in health care use, patient quality of life, or goal-concordant care between those randomly assigned to receive either ACP or usual care.

Why Does ACP Not Achieve Its Desired Outcomes?

The inability of ACP to achieve its desired outcomes represents the gap between hypothetical scenarios and the decision-making process in clinical practice settings. The success of ACP depends on 8 steps: (1) patients can articulate their values and goals and identify which treatments would align with those goals in hypothetical future scenarios; (2) clinicians can elicit these values and preferences; (3) preferences are documented; (4) directives or surrogates are available to guide clinical decisions when patients’ preferences have not changed and they lose enough decisional capacity for their ACP views to become operative; (5) surrogates will invoke substituted judgment (make the decision the patient would make if they were able) and base their treatment decisions on the patient’s prior stated preferences; (6) clinicians will read prior documents and integrate patient preferences into conversations with surrogates; (7) previously expressed wishes will be honoured; and (8) health care systems will commit resources and care delivery to support goal-concordant care.

Scenarios and situations in clinical practice settings rarely reflect these conditions. Treatment choices near the end of life are not simple, consistent, logical, linear, or predictable but are complex, uncertain, emotionally laden, and fluid. Patients’ preferences are rarely static and are influenced by age, physical and cognitive function, culture, family preferences, clinician advice, financial resources, and perceived caregiver burden (eg, need to provide personal care, time off from work, emotional strain, out-of-pocket or non-covered medical costs), which change over time. Surrogates find it difficult to extrapolate treatment decisions in the present from hypothetical discussions with patients that occurred in the past, piece together what the patient would have wanted, disentangle their own preferences and emotions, or challenge physicians who recommend different treatments. When a decision must be made, prior directives are often absent, poorly documented, or either so prescriptive or so vague that they cannot promote informed goal-concordant care. Moreover, treatment choices do not occur in a vacuum but are driven by financial pressures, societal capacity to support patient and family needs, and institutional/regional cultures and practice patterns.

Should Efforts Address the Problems of ACP Continue?

Some suggest that these data do not diminish the potential positive effects of ACP. Advocates maintain that although ACP is necessary for good end-of-life care, it is not sufficient. Why not promote and incentivize conversations with patients regarding their future values, goals, and treatment choices?

The problem with accepting these arguments and continuing along the current path is the potential for unintended consequences. Encouraging the belief that ACP is essential to good end-of-life care meaningfully detracts from other initiatives. For example, health care institutions are incentivized to devote resources that promote and measure ACP and thus direct them away from equally and perhaps more important areas of clinical care. Research demonstrates that patients leave clinically-based ACP sessions with serious misconceptions about life-sustaining treatments and that advance directive are often misinterpreted by physicians, families, and surrogates.8 In addition, the presence of an advance directive can inhibit current discussions about goals of care; this occurred in overwhelmed hospitals during the COVID-19 pandemic when treatment decisions were made according to written documents rather than discussions with patients or their surrogates.

If ACP is not essential to high-value end-of-life care, then what is? One approach is to encourage the appointment of a trusted surrogate decision-maker (health care proxy) in advance and to focus research and clinical efforts on improving current shared decision-making between proxies and clinicians. Psychometrically valid patient-reported outcomes, including the presence and severity of symptoms and health-related quality of life, can be measured in real-time; others, such as experiences of “feeling heard and understood by their clinician” and “receiving desired help for pain,” are being field-tested. Surveys of surrogates after the death of the patients they have represented are now a standard quality measure within the Veterans Health Administration, have shown good linkages with health care processes, and are a more direct measure of patient and family end-of-life experience than the occurrence of an ACP discussion.

The history of ACP is the story of science working.

There was logic to the belief that ACP would lead to better care for seriously ill patients. During the last 25 years, studies have evaluated ACP with various methods and across large groups of patients. Despite the intrinsic logic of ACP, the evidence suggests it does not have the desired effect. Many clinicians may be disappointed that promoting conversations with patients well in advance of needed medical decisions has not improved subsequent care as hoped. The new research focused on training clinicians and preparing patients and families to engage in high-quality discussions when actual (not hypothetical) medical decisions must be made is needed to achieve the outcomes that ACP has not. The clinical and research communities should learn from the evidence that does not support prior hypotheses and proceed with different approaches to improve care for seriously ill patients.