A Fair Advantage: Palliative Care Choice

1. Dr. Patrick McDaidMacmillan Palliative Care GP Facilitator Camden and Islington mcdaid@nhs.net 07939 119 131

2. A fair advantage facilitates choice. • Putting on your GSF Supportive and Palliative care Register gives your patient an advantage. • Palliative Care appears on their problem list and Alerts can be added. • It is difficult to broach end of life issues, all the more so if out of sight, out of mind

3. Proportion of total deaths occurring in hospitalsIslingtonregistered population, 2006 - 2009 This is statistically significant. Confidence intervals do not overlap

4. Proportion of total deaths occurring in hospitalsIslingtonregistered population, 2006 - 2009 57.7 60.0 56.6 59.1 Camden showed no significant shift Over the same time period the proportion in hospital is more or less unchanged

5. QOF Year end Palliative Care Register Sizes 447 292 233 225 214 154 Islington has a smaller population than Camden. Aproximately 214,000 vs 249,000. The Islington Endof Life Care LES launched in the summer of 2009. The Islington PBC LES After Death Analysis Audit was launched in the summer of 2008.

6. Potential saving of Financial resources 707-609 = roughly 100 less deaths in hospital X aprox £4,000 per death = £400,000

7. A fair advantage facilitates choice. • Palliative Care appears on their problem list and Alerts can be added. • It is difficult to broach end of life issues, all the more so if out of sight, out of mind

9. Who will benefit? If clues exist and we are hesitating just think

10. What next? (1) • Palliative care, a focus on symptom control and quality of life, is applicable to all stages of a life limiting illness. • Still, if we offer a place on our practice palliative care register to a cancer patient they might well ask “Have I had the optimal treatment for my cancer?” • Those with a none cancer condition deserve the same

11. What next? (2) • Then ask “Are you interested?” Most will say “Yes”. • Remember. No decision about me without me.

12. SPICT www.spict.org.uk

13. “Dying matters” makes it simple • Q. When is it easy to have an end of Life conversation ? • A. When the patient wants to have it. • Q. When is it hard? • A. When the patient doesn’t .

14. How do you know when someone is in their last year of life? conceptual What can you do with that knowledge? Be alert to the clues that exist Prioritise, be pragmatic, optimise care Open the door for conversations Plan for now and the future Add alerts, share information Look after your self - you are your main resource

15. Add to that • NIVNon invasive Ventilation. • Have they had it? • Do they have it overnight? • Bear in mind. • How many of us in similar circumstances might question our own mortality?

16. What effect can that can have on the last year of life? This is an extract from a Handover form: NICE COPD guidance 2010 had been followed Mr. C is Now RIP

17. The Challenge • The challenge is how to give the opportunity for a discussion while not imposing one. • GPs are very good at discussing difficult issues with patients once the conversations get going. • Frequently the bottle neck is opening the door to the conversation that is there to be had.

18. How common is this? And not just with End of Life Care... The Picture is from the Spotlight: on Palliative Care beyond CancerBMJ 16th Sep2010

19. …it’s basic General Practice to explore concerns and expectations. Sexual health Acne Depression Sick notes Continance “What’s your greatest health concern?” The Picture is from the Spotlight: on Palliative Care beyond Cancer BMJ 16th Sep2010

20. Opening the door to the conversation that is there to be had.

21. In challenging terrain wear comfortable shoes! Phrases that are at home in your everyday consultations

22. To provide an opening…use an open question For example • What’s the main thing on your mind? • What's your greatest health concern? • How do you see the future? • What are your priorities? • You can add…if you want…given your state of health. • Who’s at home and what will they want to know we talked about? • “Wear comfortable Shoes”Use phrases that are equally at home in everyday consultations.

23. Trigger events • More patients will respond positively to the openings provided if recent events have caused them to question their own mortality or future health, e.g. • The diagnosis or progression of a life limiting disease • New treatment options to consider • Just come out of hospital “close call” • The death of a spouse or close friend • A need to consider a different care setting • Changing circumstances, e.g. within the family or retirement,

24. If at first they don't engage.. • And you want to press, then take the initiative by moving from open to more focused questions • e.g. given everything that’s been going on I wonder if it would help to talk about some of the practicalities you (loved ones) may be faced with

25. Go with the flow • Watch all of their language • body language, eyes • verbal tone • direct responses • If they are not engaging or if you are meeting active resistance then don’t insist, postpone“Perhaps that’s a conversation for another time..” • A BIG PLUS: They will have learnt you are comfortable with the conversation

26. How do you know when someone is in their last year of life? conceptual What can you do with that knowledge? Be alert to the clues that exist Prioritise, be pragmatic, optimise care Open the door for conversations Plan for now and the future Add alerts, share information Look after your self - you are your main resource