End of Life Care: Advance Care Planning

1. End of Life Care:Advance Care Planning

2. Confidentiality Shared learning One at a time Respect one another’s opinions Positive critique Sensitivity Time-out Mobile phones/pagers off please Any more?........ Ground Rules

3. Learning Outcomes By the end of the programme the practitioner will be able to: Develop their knowledge and understanding of the concepts of Advance Care Planning and the Liverpool Care Pathway and their application to practice

4. Advance Care Planning

5. Advance Care Planning (ACP) What do you understand by the term advance care planning? What is the difference between advance care planning and care planning? How many of you have been involved in Advance Care Planning?

6. End of Life Strategy (2008) “All people approaching the end of life need to have their needs assessed and their wishes and preferences discussed.”

7. Advance Care Planning • A process of discussion between the individual and their care providers, irrespective of discipline. • Family/carers may be included if the individual wishes. • It is a voluntary process. • It is recommended that with the individual’s agreement this discussion is documented, regularly reviewed, and communicated to key persons involved in their care. • County-wide ACP Document – ‘Planning for Your Future Care’ • The document is held by the individual

8. The discussion may include the individual’s Concern’s and wishes Values and goals of care Understanding of their illness and prognosis Preferences for care or treatment that may be beneficial in the future and the availability of these And usually takes place in anticipation of a deterioration in a person’s condition in the future where they are not able to make decisions and/or communicate their wishes

9. Why is ACP different to other planning ACP is undertaken in the context of an anticipated deterioration in the individual’s condition with the attendant loss of capacity to make or communicate decisions Killick et al.(2010)

10. Relevant Documents http://www.endoflifecareforadults.nhs.uk/eolc/acp.htm

11. Activity Split into 4 groups and take 15 minutes to discuss the following: • In what situations in your practice may an individual wish to consider ACP? • What considerations need to be taken into account when initiating a ACP discussion? • What are the benefits and challenges that ACP presents

12. Situations in which an individual may want to consider ACP Life changing event – death of spouse Following a life threatening diagnosis Deterioration or significant shift in treatment focus During assessment of individuals needs Following multiple hospital admissions In case the unexpected happens Future planning

13. Considerations that need to be taken into account when initiating an ACP discussion Voluntary Respectthat the client may not wish to confront future issues Client Centred Dialogue ? Family/ carer involvement in discussion. Who is the most appropriate to carry out this discussion?

14. Be prepared P- prepare for the discussion R- relate to the person E- elicit pt and carer preferences P- provide information A- acknowledge emotions and concerns R- realistic hope E- encourage questions D- document • Know our own limitations and who to go to for advice or refer on

15. Appropriate communication skills Knowledge of support, services and choices available in the particular circumstances. The professional must have adequate knowledge of the benefits, harms and risks associated with treatment for client to make informed choice.

16. Choice of place of care and how that may influence treatment options Client has the Capacity to understand, discuss options available and agree to what is then planned

17. What are the benefits and challenges? Client centred approach Choices Empowerment Communication Confidence Documentation Hope

18. National End of Life Programme

19. Terms used within ACP What do you understand by the following terms? Advance Statement Advance Decision Lasting Power of Attorney

20. Advance Statement Not legally binding A written record Reflects individual’s aspirations and preferences or general beliefs and aspects of life they value Helps staff in identifying how clients wish to be cared Can help if there is a need to act in the ‘best interest’ of the client

21. Advance Decision Used to be called Advance Directive / Living Will An advance decision must relate to a specific treatment and specific circumstances Legally binding if valid and applicable to the circumstances It only comes into effect when the individual has lost the capacity to give or refuse consent.

22. Advance Decisions to Refuse Treatment ‘a decision you can make to refuse a specific medical treatment in whatever circumstances you specify’ Over age 18yr, has mental capacity Written or verbal Must be written/signed and witnessed if it includes a refusal of life sustaining treatment Should be guided by a professional with appropriate knowledge Only becomes active when patient loses capacity Applies only to a refusal of a treatment

23. It is not valid ….. If it is withdrawn by the individual who made it A Lasting Power of Attorney has been created subsequent to the advance decision The individual has done anything that is inconsistent with the advance decision. Does not apply to the specifically stated circumstances (Consideration may be given to long lapses of time during which medicaltreatment advances have been made.)

24. Relevant Documentation http://www.endoflifecareforadults.nhs.uk/eolc/acpadrt.htmlevant

25. Advance Care Planning and the Mental Capacity Act (2005) Advance Care Plans must meet the requirements of the Mental Capacity Act (MCA). Assumed to have capacity Supported to make own decisions, even if it is unwise Best interests Least restrictive of their rights and freedom

26. Lasting Power of Attorney (LPA) LPA’s can • Cover health and welfare decisions • Be registered at any time and MUST be registered before they are used • Attorney’s acting under LPA act in accordance with the principles of Mental Capacity Code of Practice. The Law Society (2010)

27. References Department of Health (2008) End of Life Care Strategy. London: DH Department of Health (2010) End of Life Care for All (e-ELCA), accessed on 01/12/2010 http://www.e-lfh.org.uk/projects/e-elca/index.html Henry, C. & Seymour (2008) Advance Care Planning: A guide for health and social care staff, Department of Health, accessed on 31/08/2010 http://www.ncpc.org.uk/download/publications/AdvanceCarePlanning.pdf Killick, S., Pharaoh, A. & Randall, F. (2010) Advance care planning in care homes, Palliative Medicine, Vol 24, No 4, pp. 445-446. The Law Society (2010) Assessment of Mental Capacity, Capacity to consent to and refuse medical treatment and procedures., Chapter 13, 3rd edition pp. 130-131. NHS Gloucestershire (2010) Planning for Your Future Care, Advance Care Planning.

28. Resources Advanced Care Planning- www.endoflifecare.nhs.uk Advance Decisions to Refuse Treatment- A guide for Health and Social Care Professionals- www.endoflifecareforadults.nhs.uk Good Decision Making-The Mental Capacity Act and End of Life Care- www.ncpc.org.uk National End of Life Care Strategy-www.dh.gov.uk/publications Planning for your Future-A Guide- www.ncpc.org.uk Preferred Priorities for Care-www.endoflifecare.nhs.uk

29. Any questions?