What are Level of Care Forms?

• Level of Care (LOC) forms are primarily completed in long term care homes.
• The intent is to record general statements about the care a resident would want in the event of a sudden change in their present condition. 
• They often include tick boxes that list care options in four or five levels, from full care with resuscitation (full code) to lesser degrees of intervention, with the lowest level being “comfort care only”.
• They often include information about whether a resident would want transfer to a hospital for care and in the even of transfer, these forms will accompany the patient. 
• Because they are a part of a resident’s chart it is assumed that healthcare providers and staff use these forms to determine what care to provide to the residents. The problems with this are described below.

What are the problems with using level of care forms in LTC?

Although it may be temping to use forms like this, there are many problems with their use.

1. Because they are part of the chart, these forms may mislead the health practitioners in thinking that consent has been obtained for treatments or transfer to hospital. These forms are not consents to treatments as they are not specific to any treatments and not specific to the individual resident and their particular health condition. Healthcare providers must still talk to either the capable resident or the incapable resident's SDM before initiating treatment or transfer. 
   
2. They contain vague statements about a general philosophy of care and should not be used to limit care offered to a resident.  These forms do not assist health practitioners in fulfilling their duty to get an informed consent to specific treatments from the right person, the resident or the incapable residents SDM
   
3.  Although often referred to as “advance care planning documents” by many long term care homes, there is a serious question about whether the execution of these forms is a valid expression of a resident’s “wishes”. Or if the resident was capable at the time the forms were completed. Recall that advance care planning and prior capable wishes are information for the SDM to use (when the resident is incapable) to help guide decision-making.  The forms, as usually drafted, give little guidance to the resident’s SDM when the SDM is called upon to make decisions for the resident when incapable because the forms are so broadly worded.
4. There is a lot of variability regarding how much of a discussion occurs before the LOC forms are completed. Were the resident or their SDM given an opportunity to explore their understanding of their current health conditions and how they may progress? Was there a discussion of the resident's values, goals and what contributes to their quality of life? Was it explained to the resident or SDM how a level of care form would be used by the health team members? 
5. Often the form is presented as “required” by the long term care home although any advance care planning should be voluntary. In some cases residents who want to record their wishes in their chart using different forms that are more meaningful to them and their SDM, are told that only the facility form may be used.
6.  These forms have been misused to not transfer a resident to a hospital for treatment just because the form said "no transfer". It is not possible to give a blanket direction about transfer to hospital in advance of a health incident. Although a resident may express a wish that at end of life they would not want transfer to hospital and would prefer that the long term care home be their place of death, they might want transfer to hospital to receive treatments for injuries or illnesses that cannot be treated at the long term care home, with return to the long term care home post treatment. The decision of transfer to hospital must be specific to the needs of the patient at the time that transfer is considered and cannot be a blanket direction.

What are the problems with using LOC forms in Acute Care/Emergency Department?

• The very need for transfer to acute care represents a change in the LTC resident's condition. 
• When there is a change in condition, health care providers must complete a medical assessment and offer treatments or treatment plans based on that assessment. 
• Given all of the variability and issues with their completion in LTC, it cannot be assumed that the LOC forms are an accurate representation of the residents prior wishes.
• Even if the LOC were to be considered prior wishes, they are information for the SDM an NOT the healthcare provider. 
• Level of care forms cannot be used to limit treatments offered to a resident once they arrive in hospital. It is the responsibility of healthcare providers in the acute care hospital to complete their own assessments, goals of care conversations and propose treatments based on the condition of the resident when they arrive at the hospital. 

Key message and suggestions for improved practice

• The wishes on level of care forms should not be driving the care provided to residents. Although some LOC forms correctly state that wishes expressed are not consent to treatment, it would appear that LOC forms are used as consents or used to limit treatment options because health care staff and health practitioners in those homes assume that these forms record consents. This misuse occurs in LTC and hospitals. Healthcare facilities should work towards improved practices for obtaining valid informed consent.
• The alternative to LOC forms is changing practices to ensure that plans of treatments are developed for all residents that include treatments such as CPR/ No CPR and that informed consent is obtained for all treatments and plans of treatments.
• Values-based conversations that focus on what is important to the resident and what they value should be incorporated into routine care. When there are no treatment decisions to be made, encourage planning conversations where residents and their SDMs learn about the resident's health conditions and are prepared to make future decisions.
  

Some examples of LOC form alternatives

Caressant Care has developed these alternatives to LOC forms. They are documentation of a goals of care conversation and a separate documentation of code status.

GOC Documentation Code Status Documentation