Put it in writing and make your wishes known

Vanderbilt Law School student Jenae Ward, left, and Vanderbilt University School of Nursing student Breanna Baraff, right, discuss advance directive materials with patient Leona Campbell. Baraff receives VUSN’s Helen Tanley Alford Scholarship. Photo by Susan Urmy.

Many nurses have been there. They’ve provided information and support while distraught family members tried to decide what their loved ones would want in terms of end-of-life care when they couldn’t decide for themselves.

Some have been part of an intense, fast-moving team working to save a terminally ill patient’s life after she coded. Others have had to explain to a patient about to undergo surgery why he needed to designate someone to make care decisions if he couldn’t make them for himself.

How much better it would be if patients had advance care plans — living wills, durable powers of attorney for health care, medical directives — so that their personal wishes could be known.

A team of Vanderbilt University School of Nursing students and Vanderbilt Law School students are working to make that happen.

The Medical-Legal Partnership Clinic project allows older adults who need advance care plans and health care/financial power of attorney documents to get them easily and free of charge. The partnership utilizes 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.

Inside the hospital clinic 

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 assure 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 the patients have access to private, face-to-face counseling sessions.

School of Nursing Assistant Professor Carrie Plummer, PhD, MSN’05, established the program, which is funded by a grant from Nashville’s West End Home Foundation. She 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.”

Vanderbilt Adjunct Professor of Law Anne-Marie Farmer, JD’03, 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.

Information first

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.

The law students participate in the project through the law school’s Geriatric Clinic Medical Legal Partnership Practicum, which Farmer teaches. Before starting work at the clinic, the eight second-year students received 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 having springing 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, explaining that a springing POA ‘springs’ into effect only when the person becomes incapacitated. “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 and provide blank ACP forms in stamped, preaddressed envelopes so that the patients can mail them back to the clinic to be added to their electronic health records.

By documenting their personal wishes and preferences, patients assist their family and physicians’ intense decision-making at what can be an emotional time. Advance care directives also ensure patient autonomy and dignity with medical care based on the patients’ own choices.

Peer partnerships

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.”

Farmer previously led a clinical course for Vanderbilt Law School students that was part of a medical-legal partnership program with Nashville’s VA Hospital. “I believe this is the first partnership with the nursing school, and also the first one where legal services are provided onsite in the medical office rather than at the law school,” she said.

Clockwise from bottom left, patients Joanne Sonnenblick and Steven Sonnenblick sign advance care directives after a discussion with Vanderbilt Law student Dean Balaes and Vanderbilt School of Nursing student Kaitlyn McGowan. Sara Weaver, of the Law School’s Legal Clinic, waits to notarize the forms. Photo by Susan Urmy.

McGowan says she appreciates being able to work with law students in a nontraditional interprofessional team. “Many of us are beginning our careers as young professionals and it is extremely important to learn how to collaborate with others outside of our specific domains,” she said. “It was an exciting partnership.”

Law student Dean Balaes, BA’15, sees the project as an opportunity to serve. Balaes, who receives the Keith-Glasgow Scholarship Fund in Law and the John and Susan Gorman Scholarship, says, “Everyone has exceptional needs. It is the job of lawyers and medical practitioners to listen and serve those individual needs. Otherwise, we risk being a source of harm rather than a source of aid.”

“Individuals should not feel that their concerns will be dismissed,” he continued. “The medical and legal partnership is a promising opportunity to fulfill this sense of service.”

The project’s core audience is older adults for whom obtaining legal assistance in creating documentation would be a financial hardship. During the planning stage for the project, adult primary care clients at the Vanderbilt Senior Care Clinic were screened to assess eligibility. Those who met the program’s criteria were sent informational letters explaining that the students would be available to talk with them at the patients’ next clinic appointments.

Patient response

Powers said that the clinic has both produced and 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 considers the program 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 adults across various health care settings, Plummer said she has seen many cases where patients’ health has been 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.

Michael O'Donnell and Mary Spitler

Patient and VUMC employee Michael O’Donnell assures Vanderbilt Nursing student Mary Spitlerthat he will review and return the advanced care directive she discussed with him. Spitler is a recipient of the Burrus Medical Scholarship for Nurses.

McGowan, who is studying to be a women’s health and adult-geriatric primary care nurse practitioner, said she intends to have conversations about the importance of advance directives and power of attorney with all of her patients in the future. “I hope one day an advance directive becomes standard for every individual and that people feel empowered making decisions for their own end-of-life care before that time comes,” she said.

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

by Nancy Wise