Advance Care Planning
Advance Care Planning is important for everyone, but it is especially important for those facing a life-limiting illness such as chronic kidney disease. It includes thinking about, talking about, and documenting healthcare wishes in the event that a person is unable to communicate or make healthcare decisions on their own. It's a process that can help a person make healthcare decisions now and for the future to ensure their voice is always heard.
Patients should have a Green Sleeve with a documented decision for CKM. The Goals of Care Designation (GCD) Order should clearly state that the patient has chosen not to have dialysis. The patient and family should know where to keep it (on or near the fridge) and they should bring it with them to any medical appointments or if they have to go to the hospital.
A CKM alert label should be placed on the bottom right corner of the patient's Green Sleeve.
Note: Do not obscure the patient name on the GCD order.
GFR 15 - 5 | Slow Decline or Deteriorating | Last 0-5 years of life
Once a patient has chosen CKM, initiate Advance Care Planning and discuss the patient’s goals of care. Ensure that the patient has a signed Goals of Care Designation Order that reflects their wishes and health status.
GFR 5 - 0 | Intensive/Near Death | Last 0-2 months of life
Review the patient’s advance care plan and preferences for end of life care with the patient and their family/loved ones. Make the necessary arrangements to ensure the patient’s wishes are honored. Discuss and update the Goals of Care Designation Order to C1 or C2.
Additional Resources
- AHS Conversations Matter
- Advance Care Planning and Goals of Care Discussion Guide for Healthcare Providers
- Advance Care Planning and Goals of Care Discussion Guide for Healthcare Providers - bifold brochure for printing
- Advance Care Planning Tracking Record
- Goals of Care Designation Order
- CKM Alert Label for Green Sleeve
- End of Life Plan
- Palliative End of Life Postcard
