Talking about Living and Dying Well

1. Talking about Living and Dying Well

2. Scottish Government Palliative and End of Life Care Action Plan • “Building on Progress” – particular priority: • early identification of patients who may need palliative care • • advance/anticipatory care planning (ACP) • • palliative and end of life care in acute hospitals • • electronic palliative care summary (ePCS) • • do not attempt cardiopulmonary resuscitation (DNACPR)

3. Palliative care - trajectories Function Function High High Death Death Low Low Time Time Erratic decline eg Organ failure Rapid decline eg. Cancer Function 5 High 6 7 2 Death Low Other Time Gradual decline e.g.Dementia, frailty GP has 20 deaths per list of 2000 Patients per year

4. Advance Care Planning A process of discussion between an individual and their care providers irrespective of discipline • May lead to development of • Statement of wishes • Welfare Power of Attorney • Anticipatory Care Plan (ACP)

5. *Prepare for the worst but hope for the best*

6. Anticipatory Care Plan (ACP) • Dynamic document for healthcare professionals recording; • care wishes • - eg preferred place of death, Rx not wanted • management plan for predictable acute events • - eg anticipatory drugs • Ceilings of treatment / levels of intervention • DNACPR

7. Anticipatory Care Plan examples Electronic Palliative Care Summary (ePCS) - GP “owned” - available to ambulance, A&E, NHS 24, acute admissions etc - consent at the point of creation not viewing Electronic Key Information Summary (eKIS) - for anyone with long term condition - process and communication as for ePCS

8. Case 1: Mrs Roberta Smyth INTRODUCTION: 63 year old lady, attends GP for INR check following recent discharge from hospital (COPD exacerbation and pulmonary embolism) PMHx: COPD diagnosed 5 years ago Alcohol excess # Neck of Femur – 2 years ago (pinned) Osteoporosis Angina Hypertension

9. Mrs Roberta Smyth Social History: Lives with husband Joe in 2nd floor flat Retired textile factory worker Retried 6 years ago because of poor health Smoker (20/day since the age of 18) 2 daughters, one lives locally, other in Cornwall Attends the bingo twice a week

10. Mrs Roberta Smyth Medicines: Warfarin (new) Alendronate + Calcichew Simvastatin Bisoprolol Lisinopril Thiamine Vit B CoStrong Prednisiolone 10mgs Seretide

11. Case Two: Mrs Macleod ‘Bad’ UTI Diagnosed Diabetes Mobility dipped TIA AF Memory Decline Vascular Dementia Metformin Gliclazide Warfarin Perindopril Indapamide Atenolol

12. Case Two: Mrs Macleod

13. For both cases… What happens next?

14. Talking about difficult things • What are the key Anticipatory Care Issues that can / should be raised at each stage? • What are the key conversations that might help later? • What are the hoped for impacts for the patient and the health service?

15. Case Two: Mrs Macleod ‘Bad’ UTI Diagnosed Diabetes Mobility dipped TIA AF Memory Decline Vascular Dementia Metformin Fall and colles fracture Gliclazide Warfarin Haloperidol Husband dies Perindopril Alendronate Temazepam Indapamide Codeine Calcichew D3 forte Infection and admitted Atenolol

16. Key Issues Mrs Macleod • Power of Attorney • Balancing drug effect v risk • Support informal structures prior to collapse • Awareness by all of stage of illness • Changing ceilings of therapy at different stages

17. Key Information on an anticipatory care plan • Contact numbers for Relatives/ Cares • Contact numbers for community nursing team • List of main active diagnosis • Current drug list • Prompt to discuss Power of Attorney • Prompt to discuss CPR (where appropriate) • Brief outline of baseline functional status • Preferred direction of travel in case of illness • Community Hospital • Main hospital • Remain in care Home • Plan in case of deterioration • Including reference to more detailed disease specific care plan if present • Consent to share information with Out of Hours service

18. Does it work ?? • 5,329 Anticipatory Care Plans [ACP] developed across NHS Highland • Reduction in both emergency new admissions (29%) and emergency occupied bed days (47%) for those patients who have an ACP in place. • Increase in both emergency new admissions (60%) and emergency OBDs (63%) for those patients who have a SPARRA score of ≥ 50% and who do not have an ACP in place.

19. Summary • Anticipatory Care is a continuum from diagnosis to death • ‘Thinking ahead’ conversations enable effective and person centred care through plans which record personal decisions.