July 12, 2018

Nursing, Law students help seniors with advance care plans

Older adults who need advance care plans and health care/financial power of attorney documents can get them easily and free of charge thanks to a new interprofessional pilot project involving Vanderbilt University School of Nursing, Vanderbilt Law School and Vanderbilt University Medical Center.

Vanderbilt Law School student Jenae Ward, left, and Vanderbilt University School of Nursing student Breanna Baraff discuss advance directive materials with patient Leona Campbell. (photo by Susan Urmy)

Older adults who need advance care plans and health care/financial power of attorney documents can get them easily and free of charge thanks to a new interprofessional pilot project involving Vanderbilt University School of Nursing, Vanderbilt Law School and Vanderbilt University Medical Center.

The Medical-Legal Partnership Clinic project uses teams of Nursing and Law students to introduce the sometimes-challenging topic of advance care directives to patients at the Vanderbilt Senior Care Clinic run by James Powers, MD.

The student teams meet with seniors at the clinic before or after patients’ medical appointments. They provide information and assistance in creating the medical and legal documents needed to ensure that the patients’ wishes are known and carried out if needed in the future. The senior care outpatient clinic provides in-kind office space for the medical-legal clinic, ensuring patients have access to private, face-to-face counseling sessions.

Carrie Plummer, PhD, ANP-BC, assistant professor of Nursing, established the program, directs it and oversees the nursing students’ involvement.

“A 2017 study found that less than a third of adult Tennesseans surveyed reported having an advance directive or power of attorney paperwork completed,” Plummer said. “At the same time, the majority of health care providers are not comfortable initiating discussions with their patients about end-of-life decisions and/or feel that they don’t have sufficient time to include these discussions in the primary care setting.

“This program gives nursing and law students the skills and experience to successfully engage and navigate these difficult discussions with patients while providing a much-needed service.”

Anne-Marie Farmer, JD, adjunct professor of Law, supervises the law students. She said the program offers them a valuable opportunity to learn important practice skills that are difficult to teach in a traditional class setting.

“This provides real-life experience in client interaction, particularly how to explain complex issues to clients who don’t have a background in ‘legalese’ and for whom these concepts are unfamiliar and often avoided,” Farmer said.

The nursing students’ participation is part of their yearlong Enhancing Community and Population Health (Community Health) course. Fourteen PreSpecialty students designed and developed the program by reviewing best practices, researching existing evidence-based literature, conducting site visits and creating a HIPAA-compliant database for patient data. They also underwent an intensive five-week training on clinical skills for patient and caregiver discussions on advance directives, power of attorney, dementia, health literacy and patient education, end-of-life care and difficult discussions, adult protective services and elder abuse, and Medicare 101 and Medicare scams/fraud.

Patient and VUMC employee Michael O’Donnell assures Vanderbilt Nursing student Mary Spitler that he will review and return the advance care directive she discussed with him. (photo by Susan Urmy)

The law students participate in the project through the school’s Geriatric Clinic Medical Legal Partnership Practicum, which Farmer teaches. Before starting work at the clinic, the eight second-year students receive classroom training on relevant substantive law, as well as coaching on skills such as client interviewing and counseling.

“As a nursing student discusses advance medical care planning with a geriatric patient, the law student offers to explain the significance and impact of assigning powers of attorney, which would designate someone to handle financial matters if the patient becomes unable to handle their own affairs in the future,” Farmer said. “It is essential that patients opting for a power of attorney document understand the breadth of authority they are granting to the person they designate.

“After this conversation, if the patient decides this is something they would like to utilize, the law student will draft the requested documents for the patient.”

The students also encourage patients to discuss their wishes with their families.

In preparation for talking to patients, the nursing students practiced by speaking to family members. “I have to say that my parents hated every moment of that conversation,” said student Kaitlyn McGowan. “In the clinic, it was a different story. People appreciated that we were bringing up this important issue and many had already thought to some degree about what they wanted for care at the end of their life.”

The project’s core audience is older adults for whom obtaining legal assistance in creating documentation would be a financial hardship.

Powers said that the clinic has increased awareness of advance directives in his patients. “We have seen a doubling of the prevalence of discussions regarding advance care planning among clinic patients,” he said.

Plummer said the program is an aspect of nursing’s holistic model of care. “Health is not just about diagnosing and treating disease, but also recognizing and addressing the patient’s other social/environmental needs,” she said.

As an adult-geriatric nurse practitioner who has worked with older adult populations across various health care settings, Plummer said she has seen many cases where a patient’s health was affected by legal needs that they couldn’t afford to address. She has also seen firsthand the challenges that occur when patients at end of life have not shared their wishes or set powers of attorney in place.

The project was supported by Nashville’s West End Home Foundation, whose mission is to enrich the lives of older adults through grant-making, advocacy and community collaboration.