Frail Elderly, Palliative and EOLC

1. Frail Elderly, Palliative and EOLC SCN, Reading, Thur 8th Oct 2015 Dr Jeanne Fay MRCGP DPallMed Interface Medicine, Oxford Health FT

2. www.poppi.org.uk (ONS data)

3. Oxfordshire Services Ambulatory Care / Admission avoidance including:- • Interface Medicine via Emergency Multi-disciplinary Units (based in 2 cottage hospitals, and this month, at both acute hospitals). • Hospital at Home service • Integrated Locality teams (nursing, therapy, social work access)

4. Admission Avoidance Nigel Edwards, Kings Fund 2014 50% admissions could be avoided if an alternative service was available including • H@H, • integrated community care teams, • ambulatory medical assessment units.

5. Emergency Multi-disciplinary Unit

6. EMU Patient Pathway

7. EMU • Treatment of exacerbations of long term conditions • e.g. heart failure, COPD & Asthma • Treatment of acute medical conditions • e.g. Dehydration & AKI, UTIs, Pneumonia, Cellulitis • Treatment of conditions causing loss of independence • e.g. Falls, Reduced mobility and functional performance levels • Semi-Elective Blood Transfusions • Telephone advice to GPs re community options for care • Avoidance of unnecessary emergency admissions

9. The H@H Service Part of Urgent Care Service, Launched 2011. Commissioned to provide clinical care to patients who are sub acutely ill at home. Aims: • To prevent inappropriate admission to hospital • To facilitate early discharge from acute or community hospitals.

10. The H@H Patients • Referred from any health or social care professional including paramedics. • Most are visited once or twice each day depending on their needs (can be up to QDS) • Work closely with specialist teams eg respiratory nurses, IV team , community diabetes nurses and EMU.... and with GP’s and DN’s

11. Referrals to Oxfordshire ILT • The patient is ‘complex’ Multiple health and/or social care needs requiring input more than 1 health care professional • The patient is ‘escalating’, in that if not in receipt of support today/tomorrow, they are at risk of hospital admission And/or • You are uncertain about what the patient needs and you need a pair of ‘eyes and ears’

12. Frailty

13. Frailty Frailty is a distinctive health state related to the aging process in which multiple body systems gradually lose their built in reserves to deal with challenges to health such as an infection, or even a new medication. This is different from simply having multiple co-morbidities.

14. Frailty Syndrome – BGS Definition • Falls(collapse, legs gave away, lying on floor) • Immobility(‘off legs’; ‘stuck on the loo’) • Delirium(acute confusion; ‘muddledness’) • Incontinence (or change in continence) • Susceptibility to side-effects of medication (eg confusion with codeine; hypotension with anti-depressants) BUT>50% over 80y old do NOT have frailty

15. DH Definition of End of Life Care helps all those with advanced, progressive, incurable illness to live as well as possible until they die. It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support. (2008) Focus = last year of life

16. National EoLCPriorities • Early identification of potential patients and communication of this across settings and sectors • EoLC assessment and advance care planning for all high risk patients • Enhanced community care services – ensuring effective investment in community settings to support disinvestment in acute services

17. Preaching to the converted?

18. Preaching to the converted? If so, then your challenge is to improve EOLC where you work, within your team … • Encourage and support colleagues to make realistic plans with patients and families. • Find out in advance about all the different services in your area that you might call on. • Consider impact on patients at the end of life of your commissioning/contracting decisions.

19. Find your 1% • Approx 1% of the UK population die each year (over half a million), • an average of 18-20 deaths per GP per year. • A quarter of all deaths are due to cancer, • Athird from organ failure, • Athird from frailty or dementia, • Atwelfth of patients have a sudden death.

21. Prognostic Indicators

22. The Surprise Question ‘Would you be surprised if this patient were to die within the next year?’

24. Challenges of Dementia • Dementia has uncertain time scale, diagnosis to death, more difficult to predict • Dementia Patients’ deteriorating communication skills prevents them expressing their views later on in the disease – so have the conversations early on & encourage the setting up of LPA • There is a burden of co-morbidity

25. In the UK… People with dementia are:– more likely to die in the acute hospital– less likely to receive hospice or palliative care – less likely to have their spiritual needs considered when they die (Sampson et al 2006)

26. NICE June 2010 End of Life Care for people with Dementia A Commissioning Guide

28. Case 1, Mr A, 85y PMH Ca prostate, dementia. Fall at home 18/5/15, JRH, then Comm Hosp. Found bone mets, possible liver mets. Managing a few steps with frame + 2. Admitted NH respite place Aug 15. Long term funding applied for. HPC 7w later, NH call GP, patient bed bound since admission, not eating or drinking for 4 days, ‘NH unable to provide for his needs’, & MUST be admitted to hospital same day.

29. Mr A, continued GP referral to EMU ‘for investigation of reason not eating’; 2hr 2 man ambulance crew requested 3.30pm. 6pm Call to NH – 1 registered nurse ‘on duty for 23 patients’, has already got another patient coming in same evening to take Mr As bed so admission cannot be delayed, even if H@H help. 8.30pm Mr A arrives Witney EMU, and admitted

30. Mr A, continued No hand over notes from NH (no NOK detail) No purple form with patient Malaena passed on arrival Not hypercalcaemic on iSTAT Tel to daughter – v annoyed that he had been move from NH where she had been pleased with care. Clear that he was for Palliative Care.

32. Mr B, 85y 24/12/14 PMH Myelodysplasia, CCF, T2DM; PC SOB referred to EMU because did not want Xmas admission. Seen daily in ambulatory capacity in EMU for management of Pneumonia and AKI, with H@H support evenings. 2 unit blood transfusion for anaemia (had been having them every 3 months in Oxford, last one November).

33. Mr B, continued Feb 2015 Further bout pneumonia Feb 2015, admitted by OOHGP to Oxford, and further transfusion then. March 2015, referred to EMU for blood transfusion by Haematology Nurse specialist. Advancing disease. Patient not wanting to discuss resus status nor prognosis.

34. Mr B, cont’d April 2015 Referral by GP to EMU. Agree to see monthly for blood transfusions, and prn if infections occur. July 2015, discussion EMU & Haematology, now on fortnightly blood transfusions Aug 2015 Hb 6, WCC 2, platelets 3 (previously 25); Creatinine 350. EMU speak with Haematology Consultant– prognosis 2-8 weeks.

35. Mr B, cont’d Tel EMU and GP. Challenges around Resus and prognosis discussions. Agreed joint approach, and with GP following up with home visit to wife and daughter. Goal is grandsons wedding 6w later. Agree Weekly transfusion while ambulant.

36. Mr B, Final week, rectal bleeding, DN doing cross match on Wednesday concerned. Mr B in bed. Own GP away. Discussed with EMU, advised towels, stand by morphine and midazolam… Friday, GP advised not fit for transfusion Saturday grandson’s wedding. Bride & Groom visit 6pm; passed away 8pm.

38. RCGP Pdf

40. Jeanne.fay@oxfordhealth.nhs.uk Tel. 01865 903659