From: Evaluation of an initiative to improve advance care planning for a home-based primary care service
UNDERSTAND | Understand health status through comprehensive geriatric assessment, including cognition (stage of dementia), mobility, function, nutrition, social situation, medical illnesses, medications, and trajectory. |
COMMUNICATE | Exchange of information. Provide detailed information to patients and/or family. Describe each illness and its trajectory; dementia and its stages; frailty stage; and risks associated with frailty. |
EMPOWER | Empower patient and/or family to make informed decisions, including what to do during a health crisis (i.e., an acute decline in health status). Engage patient and/or family-member in directed decision making. |
RESPOND | Respond to the health crisis, when it occurs, applying knowledge of frailty stage and advance care plans. |