A GP’s view of the causes of unnecessary and unwanted nursing home transfers to hospital……… and why we need an Advance D

1. A GP’s view of the causes of unnecessary and unwanted nursing home transfers to hospital……… and why we need an Advance Directives form which works

2. First…..The Punch Line

3. Wishlist for the new Advance Directives form • Quick and easy to complete - otherwise it is unlikely to be widely utilised. • Easy to understand and guides individuals filling out the form in regard to the most common and important medical decisions, ideally in a "tick a box" format (e.g. whether the patient wants CPR, ICU treatment, transfusions, etc.) • Minimum number of witnesses (ideally none) required to attend when the form is being completed. The Anticipatory Direction form (1995 Consent to Medical Treatment and Palliative Care Act) is not often completed because it is difficult and time consuming to get the GP, patient, medical agents, and authorised witnesses together to complete the form.

4. Easily recognised in the medical file (bright colours at the edges of the form!) so that it can be found in emergencies. • Central registry where a copy of the document must be submitted after it is completed. This registry should be accessible by health professionals quickly and at all hours (when emergencies tend to happen). • A tick box with the option of the individual to declare something like: "I do not want to be transferred to hospital unless my medical power of attorney, GP/Locum or registered nurse in charge are contacted, and only if they feel that it is absolutely necessary to control pain or distressing symptoms which cannot be managed at my residential facility/home“ • This simple sentence would change the default position in many residential aged care facilities from "when in doubt, send the resident to hospital" to "when in doubt, let the resident stay in their home".

5. Back to the beginning of my argument..………….

6. Factors making transfers more likely: • Increase in the number of the aged - “sicker” - and patient and family more demanding. • Residential facilities, who have been overwhelmed and demoralised by bureaucracy, accreditation, bad media, and continuous funding issues (and remember, they are funded federally) may feel that they owe nothing to a state funded hospital

7. A shortage of GPs prepared to look after nursing home patients and, particularly, a shortage of GPs prepared to provide the level of medical support (especially after hours) required to keep patients in facilities. Reasons include GPs… • already being overwhelmed in their practices • a generational change in GPs who are less likely to forgo a work-life balance • for nursing home work which has many more hassles such as visits, after hours work and phone calls • and is inadequately remunerated by Medicare. And a much of the work, such as the critical phone call which could stop an admission, is not remunerated at all

8. The final factor is the ever present fear of legal action by the families of residents

10. A Case Study • Woman with end stage COAD • She has no AD or the GP has only written some orders in the notes • Repeated acute exacerbations - sent to hospital every 2-3 weeks - and then sent back each time with letter stating not to send her again.

11. What happens each time is this: • She gets an exacerbation - short of breath at night - gets confused and distressed • There are no emergency or hospital avoidance plans developed by the doctor (or the home) for the resident • The GP cannot be contacted or refuses to take after hours phone calls which could sort out the situation • The locum is called - finds inadequate information about the patient in the notes with no clear medical summary • The locum and the nurse cannot find an adequate AD - there might be something written in the notes, or if there is an AD it doesn't indicate whether the patient wants to go to hospital • The locum or the nurse - feeling as if they have no legal protection and inadequate resources and medical support - call the ambulance • The ambulance officers - reluctantly take her to hospital • The casualty medical officer, although realising that this could have been handled at the nursing home, is nevertheless forced to admit her to the ward

12. It is currently the perception of lack of legal protection, rather than the reality, which often drives the decision making by nurses to send the patient in. And so the default position is "if in doubt, send the patient to hospital".

13. She was not aware that she had the option of asking not to be transferred to hospital -and she did not actually want to be - she just thought “this is what happens”.

17. The “Links” • Formal emergency and hospital avoidance planning for individual residents in facilities - ? new Medicare item number to encourage GPs work with facilities • Nursing homes having the support, skills and resources available to them to effect hospital avoidance - so that practical measures can be instituted acutely in the facility to prevent an admission  (e.g. to put the IV line in). Either the facility has to provide this internally, or bring this in from outside - ? Metro HomeLink

18. GPs to be accessible after hours to give verbal or email orders to effect a hospital avoidance plan- unlikely unless GPs are paid for these calls • Adequate medical summaries in facilities so that more appropriate medical decisions can be made by nurses and locums. Often no useful medical history regarding the patient in the notes- and the locum sends the resident into hospital because they have no background information on which to make a reasonable clinical decision. >> Consider the 2 page Comprehensive Medical Assessment Form

19. An Advance Directive form which “works” - with the six things on  the “wish list” - and particularly a line like "I do not want to be transferred to hospital……… ".  

20. The two critical wishes of the resident which the doctors and the nurses need to know in a medical crisis are: • Whether they want CPR • Whether they want to go to hospital • The issue of hospital transfer has been difficult because many residents have not been aware that they have this option, but it is also something which is much more difficult to articulate in a way which makes sense.

21. By having this line in a statewide Advance Directive form: • The option of not for hospital transfer would be put forward to the residents of facilities on a routine basis for the first time - and this would make the residents, doctors and nurses, aware that this is a legitimate option • The option is articulated in a way which it has often not been done before, and which gives everyone the appropriate "outs" • Done in a widespread and consistent way with perception (and hopefully reality) of legal protection for doctors and nurses.

22. This line would change the default position in many residential aged care facilities from "when in doubt, send the resident to hospital" to "when in doubt, let the resident stay in their home". • A “culture change”, or “change of mindset” in facilities