From National Crisis to Local Change: Addressing End-of-Life Care in a Rural North Carolina Nursing Home

Abstract

Problem: Residents of skilled nursing facilities frequently experience delayed advance care planning discussions and inconsistent Medical Orders for Scope of Treatment (MOST) documentation, increasing the risk of care that does not align with patient preferences. At the project site, inconsistent nursing staff knowledge and confidence regarding advance care planning conversations contributed to variability in MOST documentation and opportunities to improve patient-centered end-of-life care.

Background: Advance care planning (ACP) is a fundamental component of patient-centered care in long-term care settings, yet many skilled nursing facilities continue to experience inconsistent goals-of-care discussions and incomplete Medical Orders for Scope of Treatment (MOST) documentation. These deficiencies may contribute to care that is inconsistent with resident preferences, unnecessary hospital transfers, and increased emotional burden for residents, families, and healthcare providers.

Purpose: This DNP project aimed to improve end-of-life decision-making through education on advance care planning and MOST form use in a rural nursing facility. Objectives included increasing staff knowledge and confidence, enhancing patient and family understanding, and strengthening processes for accurate MOST documentation.

Methods: Guided by the Plan-Do-Study-Act framework, a multifaceted educational intervention was implemented within a rural skilled nursing facility. Nursing staff participated in interactive educational sessions addressing advance directives, hospice, palliative care, goals-of-care communication, comfort-focused treatment, and completion of the MOST form. Twenty-one nursing staff completed pre- and post-intervention surveys evaluating knowledge and confidence. Separate educational sessions were conducted for patients and family members, with 32 participants completing post-intervention surveys assessing understanding of advance care planning and confidence discussing future healthcare wishes. Quarterly chart audits were conducted to evaluate the completeness and accuracy of MOST documentation.

Results: Following implementation, 62% of nursing staff strongly agreed and 31% agreed their knowledge of the MOST form improved. Similarly, 58% strongly agreed and 36% agreed they felt more confident initiating end-of-life discussions. Among patients and families, 66% strongly agreed and 31% agreed that the educational intervention improved discussions about future healthcare wishes. Quarterly audits showed 100% of residents had current, signed MOST forms, supporting standardized documentation and better communication.

Conclusion: This quality improvement project demonstrated that structured education combined with standardized documentation processes can improve nursing staff preparedness, enhance patient and family engagement in advance care planning, and strengthen organizational practices supporting goal-concordant care. Incorporating advance care planning education into routine clinical practice provides a sustainable strategy for improving end-of-life care delivery within skilled nursing facilities.