Advance Care Planning

1. Advance Care Planning

2. Need to improve end of life care The Health Care Commission, 2007 (UK) ~54% of complaints about hospital treatment were about communication and preparation for death www.healthcarecommission.org.uk/db/documents/spotlightoncokmplaints.pdf

3. NICE Supportive & Palliative Care Guidelines 24.03.04 Patients with palliative needs are identified and a management plan discussed with MDT. Needs and preferences should be noted, planned for and addressed. Preferred place of care and place of death are discussed, noted and measures taken to comply where possible. Providers should ensure systems are in place to obtain rapid and safe discharge for those who wish to die at home. Carers are educated, enabled and supported.

4. The Gold Standards Framework A framework to deliver a ‘gold standard of care’ for all people approaching the end of their lives It is not disease specific A systematic approach to optimising the care delivered by healthcare professionals Developed from primary care for primary care On National Agenda and GPs can claim QOF points

5. The Seven Cs 1 Communication 2 Co-ordination 3 Control of symptoms 4 Continuity out of hours 5 Continued learning 6 Carer support 7 Care of the dying

6. Undertaking the Principles of GSF Appoint coordinator and lead GP/DN Formulate a palliative care register of patients Arrange regular MDTs Proactively address, record and communicate current and future needs including preferred place of care, end of life care planning, DNA CPR, pre-emptive prescribing etc Address carer’s needs Bereavement follow-up Significant events analysis/education

7. End of life care strategy 2008 All people approaching the end of life need to have their needs assessed, their wishes and preferences discussed and an agreed set of actions reflecting the choices they make about their care, recorded in a care plan. In some cases, people may want to make an advanced decision to refuse treatment should they lack capacity to make such a decision in the future. Others may want to set out more general wishes and preferences about how they are cared for and where they would wish to die.

8. Advance Care Planning Voluntary It is a process of discussion between an individual and their care provider which may or may not include family and friends. Makes clear a persons wishes if their condition deteriorates and they lose mental capacity or ability to communicate wishes to others

9. ACP can lead to:- Statement of wishes and preferences reflecting an individual’s preferences and wishes in relation to future treatment and care Medical and non-medical issues NOT legally binding Used to determine a person’s best interest should they lose mental capacity

10. ACP can lead to:- Advanced Decisionto refuse treatment Relates to refusal to specific treatment in specified circumstances Comes into effect when individual has lost capacity to give or refuse consent to treatment Assessment of the validity and applicability of an advanced decision is essential Legally binding

11. When to do it Part of routine clinical practice Initiated in patients with long term conditions or receiving end of life care depending on prognosis and pattern of disease progression Helps to avoid stress and anxiety regarding the future

12. Who Appropriate person who has rapport and can help facilitate an informed decision Individual encouraged to choose who they want to include in the discussion Does not necessarily need to be a health care professional

13. Summary

14. Lasting Power of Attorney Statutory form of power of attorney Patient chooses a person to take decisions on their behalf if they lose capacity Personal and financial welfare Register with Office of Public Guardian

15. Benefits of lasting power of attorney Manage affairs while still able Ensuring that wishes are met Peace of mind Decreasing burden on loved ones Keeping peace within the family

16. Birth Plan Advance Care Plan Preferred Priorities for Care

17. Introduction The PPC is a tool to determine and record patient and carers’ wishes in relation to their care and ultimate place of death. A nationally recognised tool for all palliative care patients. PPC has been identified within the End of Life Care Programme as an example of an Advance Care Plan

18. Identifying and Recording Preferences The explicit recording of patients/carers wishes can form the basis of care planning in multi-disciplinary teams and other services, minimizing inappropriate admissions and interventions. In relation to your health what has been happening to you? What are your preferences and priorities for your future care? Where would you like to be cared for in the future?

19. Potential triggers to introduce PPC Following life changing event Following diagnosis of a life limiting illness During assessment of a persons need Following a significant shift in treatment In conjunction with prognostic indicators Multiple hospital admissions Admission to a care home

20. PPC as an Advance Care Plan Enables initiation of End of Life Care decisions Facilitates recording of Preferences and Priorities May identify potential need for Advance Decisions to Refuse Treatment to be initiated Accessible Version enables Best Interest Process to be followed Under MCA preferences SHOULD be taken into account

21. Do Not Attempt Cardio Pulmonary Resuscitation CPR is undertaken unless a DNA CPR order exists For the vast majority of patients receiving care in hospital no advance decision is made unless CPR is thought to be futile DNA CPR is a medical decision There is now a Yorkshire and Humber generic transferable form to remain with the patient

22. When is DNA CPR appropriate? Where CPR is contrary to the competent patient’s wishes Where attempting CPR will not restart the patient’s heart and breathing Where there is no benefit in restarting the patient’s heart and breathing Where the expected benefit is out weighed by the burdens

23. Should patients be involved in DNA CPR decisions? People have ethical and legal rights to be involved in decisions that relate to them Where patients are at foreseeable risk of cardiopulmonary arrest, or have a terminal illness, there should be a sensitive exploration of their views regarding CPR Discussion should be part of general discussions about that person’s care

24. References End of Life Care Strategy. Professor Mike Richards (Chair) Department of Health. July 2008 Improving Supportive and Palliative Care for Adults with Cancer. Nice, 2004 www.endoflifecareforadults.nhs.uk www.resus.org.uk/pages/dnar.pdf www.ncpc.org.uk/publications www.dca.gov.uk/legal-policy/mental-capacity/publications.htm www.publicguardian.gov.uk/mca/code-of-practice.htm www.goldstandardsframework.nhs.uk

25. Case Scenario 55 year old man diagnosed with inoperable lung cancer April 2010. Is widowed with two teenage children. His partner has taken on the parental role and their Grandmother remains involved. Received palliative chemotherapy but discontinued July 2010 as disease progressing to bones and brain. August 2010 Received palliative radiotherapy to ribs and brain and receiving monthly bone strengthening infusions . On fentanyl patch, oral analgesia, aperients, anticonvulsants and steroids. Oct 2010 Deteriorating, becoming drowsy and bedbound.

26. Considerations for Patient What do you think would be concerns/wishes for the patient throughout this journey? How do you think the patient would wish professionals to respond to these concerns?

27. Considerations for Relatives What do you think would be concerns/wishes for the relatives along the patient journey? How do you think they would want professionals to address concerns/wishes?

28. Considerations for Professionals What Advanced Care Planning should be considered by professionals? How would you ensure seamless Advanced Care Planning? How can Advanced Care Planning be addressed?