Journal of Palliative Care and Nursing

Implementation of Advance Care Planning in a Rural Minnesota Long-Term Care Facility

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Published Date: September 11, 2019

Implementation of Advance Care Planning in a Rural Minnesota Long-Term Care Facility

Amber Reed1* and Julie Ponto2

1LB Homes – Broen Home, 824 S. Sheridan, Fergus Falls, MN 56537, USA
2Winona State University, 859 30th Ave. SE, Rochester, MN 55904, USA

*Corresponding author: Amber Reed, 1510 Viking Ct., Fergus Falls, MN 56537, USA, E-mail:

Citation: Reed A, Ponto J (2019) Implementation of Advance Care Planning in a Rural Minnesota Long-Term Care Facility. J Pall Car Nur 1(2): 109.




Objective: Advance care planning (ACP) helps individuals to discuss treatment options and health care preferences, so that in case of an emergency or life-threatening illness the individuals’ preferences can be carried out. This Evidence-Based Practice (EBP) project aimed to improve the process of discussing and documenting care preferences, and increase the number of ACP conversations and documented Advance Directives (ADs) in A Long-Term Care (LTC) facility in rural Minnesota.

Methods: Evidence-based practice implementation was used to determine whether there was a significant increase in AD completion after the intervention. The Iowa Model guided this EBP project. The setting included one 90-bed LTC facility in rural Minnesota, which included short-stay and LTC. Participants included short-stay and LTC residents without documented ADs in their medical records and LTC staff.

Intervention: Implementation of a comprehensive ACP program based upon Honoring Choices Minnesota® (HCM) that focuses on increasing awareness of preferences for health treatments and using trained facilitators.

Measurements and Instruments: Total number of ACP conversations; number of residents aged 65 years or older participating in ACP conversations; date, length of time, and location for the ACP conversations; and percentage of ADs completed were measured using the ACP Conversation and AD Completion Document. Resident satisfaction was measured using the ACP Satisfaction Survey. Staff feedback was measured using the Post-Advance Care Planning Staff Feedback Questionnaire.

Results: The percentage of residents in the care center who had an AD before (N = 77, 87.5%) increased after the intervention (N = 82, 93.2%). Five of the eight residents without documented ADs prior to implementation had a form in their medical record after the intervention. Overall, the residents found the experience to be positive; they found the discussion to be helpful (M = 4.38, SD = 0.74), felt more prepared to make decisions (M = 4.38, SD = 0.74), and felt the facilitator helped them with ACP (M = 4.50, SD = 0.53). Staff feedback supported the practice change.

Discussion: The main outcomes of this project were an increased percentage of residents who had ADs after the ACP discussions and staff support of the EBP process. One challenge identified with ACP implementation was obtaining the desired results with cognitively impaired residents due to inability to make sound decisions regarding future healthcare. Utilizing HCM ACP with younger populations in hospitals and college settings would improve the amount of documented advance directives community-wide.

Conclusions: A structured ACP process resulted in increased documented ADs. The HCM ACP process is a successful and positive intervention in LTC. Advance care planning discussions can assist LTC residents in preparing to make decisions regarding their future healthcare.

Keywords: Advance care planning; Advance directive; Evidence-based practice; Long-term care



Many individuals report receiving care at the end of life that does not meet their preferences [1]. Nearly 76% of residents at the end of life die in an institutionalized setting; however, 70% prefer to die in the comfort of their own home [1]. In 2009, 25% of adults 65 years of age and older died in an acute care setting, 33% in their home, and 28% in a long-term care (LTC) facility [2]. In addition, many people receive aggressive treatment for illnesses, although would prefer less intensive measures [1].

These data support the importance of helping residents express and document care preferences. Advance care planning (ACP) is a process of assisting residents who are able to make and communicate decisions to discuss options for treatment and individual healthcare preferences so that in the case of an emergency or life-threatening illness the preferences can be carried out. Advance care planning provides clear direction in caring for residents who are no longer able to make decisions or communicate their treatment requests [1,3–12]. Advance care plans decrease the use of aggressive treatments (e.g. CPR, intubation) when not preferred by the resident, prevent hospitalizations and unwanted high cost of cares, increase hospice and/or palliative care, and increase honoring preferences at the end of life [4,13].

Given the high number of deaths in LTC, ACP is particularly important in LTC settings. In 2014, 15,600 nursing homes provided LTC services in the United States, serving 1,383,700 residents [14]. The services provided in LTC include a variety of health and support services for residents with limited self-care capacities [14]. In 2014, the average length of stay for residents in LTC facilities in the United States was 835 days [14]. Long-term care facilities include a population of residents (i.e. residents and their healthcare agents) who are at increased risk for emergency or life-threatening illnesses, and could benefit from advance care plan conversations and assistance with completing advance directives (ADs).

Unfortunately, ACP is often inadequate in the LTC environment, which leads to a low number of documented advance care plans in resident medical records [3,8]. Nationwide, only 65% of residents in LTC have a documented AD [15].

The goal of ACP is to increase the likelihood of care preferences being honored at the end of life for residents no longer being able to communicate their requests. The completion of an AD also helps to prevent healthcare agent stress by eliminating the need for the healthcare agent to make choices for their loved one in a critical situation [1,3].

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The purpose of this evidence-based practice (EBP) project was to (a) examine the literature and implementation of EBP approaches to ACP in LTC facilities, (b) improve the process of discussing and documenting resident care preferences in one LTC facility, (c) increase the number of ACP conversations and documented ADs in that facility, and (d) analyze resident satisfaction, and feedback from facility staff.

A search of literature was conducted to review evidence on ACP implementation processes in LTC. Several academic databases were searched including, (a) ProQuest Nursing and Allied Health Source, (b) CINAHL, (c) Google Scholar, (d) PsycInfo, (e) PubMed, (f) Cochrane Library, and (g) National Guidelines Clearing house. The Institute of Medicine, Centers for Disease Control, Respecting Choices®, Agency for Healthcare Research and Quality, and Honoring Choices Minnesota® (HCM) websites also contributed literature on ACP. Keyword combinations included end of life care, end of life care and long-term care, advance care planning, Honoring Choices Minnesota®, and Respecting Choices®. Searches were limited to English language, peer-reviewed studies from 2006–2016.

Literature related to ACP implementation processes in LTC was reviewed. Sixty-six articles were reviewed, of which 19 described a process of ACP (12 research studies, five systematic reviews, and two clinical guidelines). Comprehensive ACP programs that provide training for health care providers on the ACP process and involve a series of implementation steps have shown to be successful in increasing completion of ADs [9,12,16–18]. Facilitated discussions guide the identification of present and future values and goals for medical care [16].

The LTC facility’s leadership team recognized a need to implement a structured ACP process and increase the number of documented ADs. The facility was part of a community-wide initiative grant project funded by the Minnesota Department of Human Services (DHS) which focused on increasing the number of ACP conversations and completed ADs. Minnesota has a history of supporting an early ACP process.

Evidence-based practice (EBP) is an approach to improve quality care and control healthcare costs. The Iowa Model of Evidence-Based Practice to Promote Quality Care (hereafter referred to as the Iowa Model) provided a step-by-step guide to align the clinical problem with evidence-based interventions to change practice [19]. Table 1 provides an overview of the description of the Iowa Model, as well as how the model applied to this EBP project.

Table 1: Description of the Iowa Model of Evidence-Based Practice(EBP) and Application to the Advance Care Planning EBP Project. (Note: Description of Iowa Model adapted from reference [19]).

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Setting and Participants

An EBP project was completed at one LTC facility in rural Minnesota. The facility includes short-stay and LTC, with an average length of stay of 26 days in short-stay and 57 days in LTC. The facility housed between 84 and 89 residents in short-stay and LTC during the four week project implementation period. All residents without documented ADs in their medical records were eligible to participate in the ACP project by the ACP facilitator. Residents with documented ADs in their medical records were excluded from this project.

Implementation Methods

Honoring Choices Minnesota® (HCM) is a program that focuses on increasing awareness of preferences for future health treatments and assists health care facilities and community partners with the implementation of a comprehensive ACP program [20]. The HCM ACP process is a comprehensive process that utilizes a certified facilitator trained to initiate conversations and engage residents and healthcare agents in discussions regarding future health care treatments and desires [20]. A critical component of HCM is the facilitator training where the facilitator learns how to use standard materials to assist residents and families with ACP conversations [1].

The first use of HCM in Minnesota began in 2008 in a large metropolitan area with people of diverse cultures, and was based on a similar ACP process initiated in La Crosse, Wisconsin (Respecting Choices®) [1]. Eight large metropolitan healthcare systems in Minnesota participated in the initial implementation. By April 2013, 65.6% of hospitalized adults aged 65 and older had ADs in their medical records, compared to 12.1% prior to implementation of HCM ACP [1].

The HCM process was utilized to implement ACP in a LTC facility for the EBP project. Implementation included one ACP trained facilitator who (a) assessed the resident’s understanding of ACP; (b) discussed the role of the healthcare agent; (c) promoted discussion between the resident and healthcare agent to clarify goals and values; (d) reviewed and discussed the choice of a healthcare agent with the resident; (e) identified cultural, religious, spiritual, or personal beliefs that may influence treatment decisions; (f) explored goals and preferences of future healthcare; and (g) encouraged the completion of an AD.

Human subjects’ protections during the project were ensured through Institutional Review Board (IRB) review and approval obtained from a University IRB associated with the LTC facility. The LTC Administrator provided permission on behalf of the LTC facility to conduct the project within the LTC facility and to access records. Institutional Review Board approval and Administrator permission were obtained prior to implementing the project. Eligible residents were identified with the assistance of the facility’s social worker and through medical record reviews. Informed consent was obtained from residents prior to initiating ACP conversations.

One trained ACP facilitator conducted individual discussions with eight residents in the short-stay and LTC units. A Power Point® presentation provided basic information for residents and healthcare agents on the ACP process and AD document. Interview materials provided by Respecting Choices® assisted in exploring resident beliefs and goals. Residents were offered an AD document to discuss care preferences with their healthcare agents. The trained facilitator collected information on resident and conversation characteristics at the conclusion of each conversation. Residents and staff provided feedback on the discussions. Follow-up conversations explored the need for further assistance, and all completed AD documents were placed in resident medical records.             

Measures and Instruments

The ACP Conversation and AD Completion Tracking form was used to document the total number of ACP conversations, number of residents aged 65 years or older participating in ACP conversations, date and length of time for the ACP conversation, location the ACP conversation took place, and the percentage of ADs completed at the ACP conversation session or at follow-up meetings. The form was created by the DHS ACP grant coordinator and used to document ACP conversation characteristics for grant statistics.

To meet the objective of resident feedback, the ACP Resident Satisfaction Survey measured resident satisfaction on the ACP discussions. The survey, developed by the Respecting Choices® program, measured level of satisfaction using a 1 (not at all) to 5 (very much) rating system using three Likert scale items and one open-ended question [21]. Survey items asked how helpful the discussion was, how prepared the person felt about making decisions about their future health care following the discussion, how the facilitator helped, and suggestions for the facilitator. Permission was obtained to use the survey tool.

Feedback from organizational leadership was obtained through a post-implementation interview session using the Post-Advance Care Planning Staff Feedback Questionnaire, comprised of four open-ended questions. Questions assessed strengths of the HCM ACP process, implementation challenges, the time requirement for ACP conversations, and suggestions for HCM ACP process maintenance in the facility.

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Project Participants and Process Outcomes

The EBP project compared the percentage of residents who had ADs prior to the ACP discussions with the percentage of residents who had ADs after the ACP discussions. Of the eight residents, seven were aged 65 or older. The length of time for discussions ranged from 15 to 30 minutes. The conversations took place during a four-week implementation period in both the short-stay (n = 3) and LTC (n = 5) settings. The percentage of residents in the care center who had an AD before (N = 77, 87.5%) increased after the intervention (N = 82, 93.2%). Five of the eight residents without documented ADs prior to implementation had an AD in their medical record after the intervention. Residents who completed the ACP process completed an advance directive document which included identifying a health care agent and documenting decisions for future healthcare in the areas of CPR, ventilator/respirator, nutritional support/hydration, dialysis, blood transfusions/blood products, antibiotics, pain management, organ donation, autopsy, and hopes and wishes.

Resident Satisfaction

Overall, the residents found the experience to be positive. Residents found the discussion to be helpful, felt more prepared to make decisions, and felt the facilitator helped them with ACP (see Table 2).

Table 2: Mean, Standard Deviation, Actual and Potential Ranges on the Advance Care Planning Resident Satisfaction Survey. (Note: Survey adapted from 21. The survey measured level of satisfaction using 1 (not at all) to 5 (very much) rating system.  Used with permission).

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Facility Leadership Feedback

The Administrator and Executive Director provided feedback on each of the following four areas during a post-intervention interview session at the conclusion of the project.

Strengths identified with the HCM ACP process: The identified strengths of the process included the use of a standard, consistent healthcare directive form, as well as ACP tools. Visual information in the PowerPoint® in addition to the spoken message was beneficial. The ACP Interview Tool was believed to be helpful in assuring that no discussion topics were omitted. These tools were also believed to assist in the promotion of listening and dialogue, which are vital to assuring understanding and sound decision-making.

Implementation challenges encountered with the hcm acp process: Three main challenges with the HCM ACP process were identified. Obtaining the desired results of the HCM ACP process was difficult with cognitively impaired residents due to inability to make sound decisions regarding future healthcare. Coordinating resident, family, and staff schedules so all could meet together was also a challenge. Quarterly resident and family informational meetings are provided in the facility to allow an opportunity for large group discussions and would be ideal for ACP conversations; however, attendance at these meetings has historically been low. Finding the time needed to have conversations was a third challenge when implementing the HCM ACP process.

Time requirement for ACP conversations: Although the time requirement for HCM ACP conversations was identified as a challenge, this issue was described as minor. The HCM ACP process may take time away from other activities and could be more challenging if multiple conversations are necessary in a short period of time. The time requirement was thought to be significantly less for residents who had thought about their future healthcare preferences, but had not yet completed the official AD document. Overall, the time commitment involved in having ACP conversations was found to be manageable given the benefit of having ADs available to guide resident care.

Suggestions for sustaining the HCM ACP process: Suggestions for sustaining the HCM ACP process in the facility were discussed. Facility leadership envisions volunteers trained as facilitators and available to sustain the HCM ACP process for willing and interested residents. Time budgeted for staff with whom the residents are familiar and comfortable with was recognized to further increase AD completion percentages, as well as to sustain the process. With time budgeted for staff to complete these activities, residents may be more willing to participate in ACP conversations and complete ADs with staff they know and trust. The importance of staying involved with community ACP activities to assist in sustaining the HCM ACP process was also identified.

Table 3: Advance care planning and related abbreviations and terms used in text.

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A main outcome of this project was the increased percentage of residents who had ADs in their medical records after participating in the HCM ACP process. In addition, residents indicated satisfaction with the HCM ACP process. Facility leadership identified strengths, challenges, time requirements for ACP conversations, and suggestions for maintaining the HCM ACP process in the facility. The ability to conduct discussions with residents and healthcare agents in a familiar environment with people they trust was recognized as an asset to further increase the percentage of AD document completion and project maintenance. Facility leaders involved in the project, although small in number, were from a variety of departments and included administrators, social workers, registered nurses, and chaplains. This diversity and their willingness to adopt a new structured approach to ACP assisted in the project’s success and will assist in sustaining HCM ACP in this facility.

The facility had a high percentage of residents with documented ADs pre-implementation (87.5%). Part of a comprehensive ACP process includes reviewing and updating existing ADs and ensuring the preferences are honored [21]. Though not a focus of this project, the role of the facilitator can include reviewing existing ADs with residents to identify necessary changes [21]. The frequency of review for ADs is not established; however, reviewing ADs at least annually and at the time of any changes in health condition or phase of illness is reasonable. Further research and EBP can identify how often AD review is recommended and needed. An accessible algorithm process available for staff to ensure preferences are honored during emergent situations could also be added to facilitator training.

One challenge identified with ACP implementation was obtaining the desired results with cognitively impaired residents due to inability to make sound decisions regarding future healthcare. Two residents were deemed incapable of making sound decisions during ACP conversations in the LTC setting. Assessing capacity for decision-making is an important component of ACP. Developing institutional policies for assessing and addressing capacity can help guide the ACP process in LTC. Most states have processes for appointing a legal representative if one is not identified through an AD. Further research is recommended to determine what level of impairment would prohibit a resident from participating in ACP.

The use of a Physician Orders for Life-Sustaining Treatment (POLST) can improve quality care of residents with serious illnesses by documenting medical care for emergency situations through a standing medical order paradigm [22]. The POLST allows providers to order treatments based on what the residents would want [22].

The outcomes achieved in this EBP project can impact populations beyond LTC. Utilizing HCM ACP with younger populations in hospitals and college settings would improve the amount of documented ADs community-wide. Often times when an individual enters the LTC facility, the ability to make sound decisions may no longer be a possibility. Advance care planning ideally should be completed when individuals are healthy and have the ability to explore future healthcare preferences without the stress of serious illness [23].

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Advance care plans decrease the use of unwanted intensive and costly treatments when not preferred by LTC residents and increase honoring preferences at the end of life [5,13]. During ACP conversations residents are provided the opportunity to reflect on future goals and healthcare preferences, assisted with choosing a healthcare agent, allowed time to communicate future goals and healthcare preferences, and assisted with completion of ADs. Honoring Choices Minnesota® is a structured approach to ACP that includes these implementation steps and informed this EBP project.

Educating healthcare workers and residents about ACP is important to ensure end-of-life care preferences are reviewed, documented, and honored [3–6,24–27]. Education and training of staff and using interview tools to enhance reflection on resident treatment preferences when implementing ACP can provide structured guidance and assistance in the ACP process [3–6,24–27]. Continuing to educate and train LTC staff and volunteers as ACP facilitators can increase the number of documented ADs and may actually decrease the time spent in ACP as staff become more efficient with the process.

The structured HCM ACP process resulted in additional documented ADs in the facility. Residents felt the ACP discussions assisted them in preparing to make decisions regarding their future health care. Further research regarding the correlation between HCM ACP conversations and increased AD documentation is needed.




Financial support to attend the ACP Facilitator training was provided through the DHS ACP grant, number 96240, a Live Well at Home grant. Financial support to present this EBP project at a research conference was provided through a mini-grant from the University’s School of Graduate Studies.


Conflict of Interest

Authors declared that they have no conflict of interest.

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  1. Wilson KS, Kottke TE, Schettle S. Honoring Choices Minnesota: Preliminary data from a community-wide advance care planning model. J Am Geriatr Soc. 2014;62(12):2420–2425. doi: 10.1111/jgs.13136.
  2. Institute of Medicine. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, D.C: The National Academies Press, 2015.
  3. Gilissen J, Pivodic L, Smets T, Gastmans C, Vander Stichele R, Deliens L, et al. Preconditions for successful advance care planning in nursing homes: A systematic review. Int J Nurs Stud. 2017;66:47–59. doi: 10.1016/j.ijnurstu.2016.12.003.
  4. Baughman KR, Aultman JM, Ludwick R, O’Neill A. Narrative analysis of the ethics in providing advance care planning. Nurs Ethics. 2014;21(1):53–63. doi: 10.1177/0969733013486795.
  5. Bischoff KE, Sudore R, Miao Y, Boscardin WJ, Smith AK. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc. 2013;61(2):209–14. doi: 10.1111/jgs.12105.
  6. Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A. The effects of advance care planning on end-of-life care: A systematic review. Palliat Med. 2014;28(8):1000–25. doi: 10.1177/0269216314526272.
  7. Burnett CB, Wolff B. Part 2: Nursing and advance care planning – how it’s all supposed to work and the critical role for nurses. N M Nurse. 2015;60(1):8–9.
  8. Butler M, Ratner E, McCreedy E, Shippee N, Kane RL. Decision aids for advance care planning: An overview of the state of the science. Ann Intern Med. 2014;161(6):408–18. doi: 10.7326/M14-0644.
  9. Hammes BJ, Rooney BL, Gundrum JD. A comparative, retrospective, observational study of the prevalence, availability, and specificity of advance care plans in a county that implemented an advance care planning microsystem. J Am Geriatr Soc. 2010;58(7):1249–55. doi: 10.1111/j.1532-5415.2010.02956.x.
  10. Houben CH, Spruit MA, Groenen MT, Wouters EF, Janssen DJ. Efficacy of advance care planning: A systematic review and meta-analysis. J Am Med Dir Assoc. 2014;15(7):477–89. doi: 10.1016/j.jamda.2014.01.008.
  11. In der Schmitten J, Lex K, Mellert C, Rothärmel S, Wegscheider K, Marckmann G. Implementing an advance care planning program in German nursing homes. Dtsch Arztebl Int. 2014;111(4):50–7. doi: 10.3238/arztebl.2014.0050.
  12. Stone L, Kinley J, Hockley J. Advance care planning in care homes: The experience of staff, residents, and family members. Int J Palliat Nurs 2013;19(11):550–7.
  13. Cornally N, McGlade C, Weathers E, Daly E, Fitzgerald C, O'Caoimh R, et al. Evaluating the systematic implementation of the ‘Let Me Decide’ advance care planning programme in long term care through focus groups: Staff perspectives. BMC Palliat Care 2015;14:55. doi: 10.1186/s12904-015-0051-x.
  14. Centers for Disease Control and Prevention. Long-term care providers and services users in the United States: Data from the national study of long-term care providers 2013-2014. Hyattsville, MD: U.S. Department of Health and Human Services, 2016.
  15. Jones AL, Moss AJ, Harris-Kojetin LD. Use of advance directives in long- term care populations; 2011. Available from: [Accessed August 10, 2016].
  16. Blackford J, Strickland E, Morris B. Advance care planning in residential aged care facilities. Contemp Nurse. 2007;27(1):141-51. doi: 10.5555/conu.2007.27.1.141.
  17. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: Randomized controlled trial. Br Med J. 2010;340:1–9. doi: 10.1136/bmj.c1345.
  18. Michigan Quality Improvement Commission. Advance care planning. Southfield, MI: Michigan Quality Improvement Consortium, 2014. Available from: . [Accessed April 10, 2016].
  19. Brown CG. The Iowa model of evidence-based practice to promote quality care: An illustrated example in oncology nursing. Clin J Oncol Nurs 2014;18(2):157–9. doi:10.1188/14.CJON.157-159.
  20. Honoring Choices Minnesota and Twin Cities Medical Society. Executive summary; n.d. Available from: [Accessed April 10, 2016].
  21. Briggs L, Hammes B, Anderson S. Respecting Choices® advance care planning facilitator certification manual: A guide to person-centered conversations. La Cross, WI: Gundersen Health System, 2015.
  22. National POLST Paradigm. POLST paradigm fundamentals; 2017. Available from: [Accessed April 4, 2017].
  23. Sanders S, Robinson EL. Engaging college undergraduates in advance care planning. Journal of Death and Dying. 2017;74(3):329-344.
  24. Boot M, Wilson C. Clinical nurse specialists’ perspectives on advance care planning conversations: A qualitative study. Int J Palliat Nurs 2014;20(1):9–14.
  25. Dixon J, Matosevic T, Knapp M. The economic evidence for advance care planning: Systematic review of evidence. Palliat Med. 2015;29(10):869–84. doi:10.1177/02629216315586659.
  26. Jeong SY, Higgins I, McMillan M. Experiences with advance care planning: Nurses’ perspective. Int J Older People Nurs. 2011;6:165-175. doi: 10.1111/j.1748-3742.2009.00200.x.
  27. Sechaud L, Goulet C, Morin D, Mazzocato C. Advance care planning for institutionalized older people: An integrative review of the literature. IntJ Older People Nurs. 2014;9:159–68. doi:10.1111/opn.12033.

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Copyright: © 2017 Reed A, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.