Transcript ADVANCE DECISION - City and Hackney CCG

How to Open Discussions
and
Plan care for End of life
with Patients, their Friends
and Families
Dr Natasha Arnold
Consultant Geriatrician
Aims of presentation
• Case finding/ Indentification using
SPICT(Supportive and Palliative care Indicator Tools)
• Case examples of common conditions &
approach to EOLC discussions
• Advice on Drugs
• Complex patients/ seeking advice
advice
• Legal issues to consider
SPICT non-specific indicators
• Look for >2 clinical indicators of deteriorating health:
• 1. Performance status poor or deteriorating (needs help with
personal care, in bed or chair for 50% or more of the day).
• 2. Two or more unplanned hospital admissions in the past 6/12.
• 3. Weight loss (5 - 10%) over the past 3 - 6 months and/or body
mass index < 20.
• 4. Persistent, troublesome symptoms despite optimal treatment
of any underlying condition(s).
• 5. At risk of dying from a sudden, acute deterioration ( reflect on
history).
• 6. Lives in a nursing care home or NHS continuing care unit, or
needs care to remain at home.
• 7. Patient requests supportive care and needs palliative care as
result of treatment withdrawal.
SPICT specific indicators
• Advanced Cancer
• Advanced CVS, RS, CKD and liver
disease.
• Advanced Neurological disease
• Advanced Dementia/ Frailty-less good
as too subjective and open to
interpretation.
Case of 78 year old house bound
lady
• HT 25 years, Type II DM 15 years on Insulin
• IHD with 2x MI and CABG 5 years ago with
complicated recovery now advanced
CCF/LVF with SOB at rest
• CKD stage 4/5 -3x admissions last 6/12 AKI
• Registered blind and housebound since 2010
with PoC Tds sith supervised transfers, with
x1 bed/chair/commode
• How would you start discussions?
How would I start these
conversations
• Patient Reflection of health/ ill health and
admissions recently
• Patient interpretation of where their health is
going in the future
• What issues they have found makes living
harder or easier at home or in hospital
• Have they had thoughts about dying and
what they fear or would like to happen around
their own death?
Case of 84 yr man house bound in
nursing home
• Lewy body dementia for 2 years
• Bed bound with catheter
• Hoisted and risk fed up right with soft moist
diet.
• 3x admissions with delerium due to aspiration
pneumonia, AKI and UTI in last year
• Daughter visits every1/12 and she wants him
escalated to hospital for any deterioration.
She has been asking staff about invasive
feeding
Is there a right way to open
these discussions?
How perhaps not to do it?
Symptom prevalence in advanced disease
(Solano, Gomes & Higginson, Journal Pain & Symptom management. Jan 06)
Cancer
• Pain
35-96%
• Confusion
6-93%
• Anorexia
30-92%
• Fatigue
32-90%
• Anxiety/depression
3-79%
• Dyspnoea
10-70%
• Insomnia
9-69%
• Nausea
6-68%
Cardiac failure
• Dyspnoea
60-88%
• Fatigue
69-82%
• Pain
41-77%
• Anxiety/depression
9-49%
• Insomnia
36-48%
• Nausea
17-48%
• Constipation
38-42%
• Anorexia
21-41%
Drug review priorities
• Refer to Tower Hamlets drug review in
LYOL advice in pack
• Broadly think of stopping in sequence:
– Primary prevention drugs
– Secondary prevention drugs where the morbidity
related LTC is already at end stage
– LTC treatment drugs- review symptoms and cut
those out that exacerbate or cause additional
symptoms and negotiate around those that still
have a role in managing the LTC.
EOLC discussions to ACPs
•
•
•
•
•
Indentification with SPICT
Complex ? Role of Geriatrician
Role of One Hackney MDT
Palliative care team and St Josephs
CMC
How CMC can assist care providers:
Increases the number of patients with an
advance care plan
Preferred place of care and dying
achieved
Integrated service provision from all
primary care sources
Reduction in number of unnecessary
hospital admissions
Reduction in the cost of hospital stay
Reduction in length of stay in hospital
12
When do you consider DNAR
decisions?
And when should you?
What do you do when you have
considered?
What is the difference
between Advanced Care
plans and Advanced
Directives?
Consider in context of PPC, One
Hackney ACP vs CMC ACP and
escalation plans vs ceilings of care
DEFINITION OF AN ‘ADVANCE
DECISION’
“Advance decision” is a documented decision
made by an adult with capacity that if:
(a) at a later time a specified treatment is
proposed to be carried out by a person
providing health care, and
(b) at that time he lacks capacity to consent to
that treatment,
That specified treatment is not to be carried out
or continued.
When Advanced decisions are
not binding






Person lacked capacity to make it
Person still has capacity, so can take own
decision
Person changed their mind when they still had
capacity
It is not the treatment specified
It is not the circumstances specified
Person may not have made it had they
anticipated the current circumstances
Lasting Power of Attorney

A lasting power of attorney is a power
of attorney under which the donor ‘P’
confers on a donee or donees
authority to make decisions about all
or any of the following:

P’s health and welfare or specified
matters concerning P's personal
welfare

P’s property and affairs or specified
matters concerning P's property and
affairs,

An LPA includes authority to make
decisions in circumstances where P
no longer has capacity.
LPA
Personal Welfare
Property
Affairs
• http://www.legislation.gov.uk/ukpga/2005/9/contents
• National Council for Palliative Care ‘Advance
Decisions to Refuse Treatment – a guide for health &
social care professionals’
• BMJ Oct 2013 A.Mullick, J Martin ‘An introduction to
advance care planning in Practice’.
What do you want to
know about
identifying and
managing those
approaching end of
life?