Transcript Advance care planning evaluation in sick, elderly patients

"If I don't talk about it and
it's not written down, how
will anyone know my
wishes?
If I were unable to
communicate with anyone,
and there were things that I
really wanted
or didn’t want,
How would I feel?”
Advance Care Planning in Canada:
You Can Do It!
Faculty:
Louise Hanvey, Advance Care Planning in Canada
Cari Borenko Hoffmann, Fraser Health, British Columbia
Dr. Jessica Simon, Calgary Zone, Alberta Health Services
Disclosures: No conflict
We do have a confluence of interest
Goals & Objectives
1. Describe the role of various health care providers
in initiating, continuing and facilitating advance
care planning conversations.
2. Identify the optimal topics to include in ACP
conversations based on the health status of the
individual involved.
3. Acquire skills for initiating and continuing advance
care planning conversations.
4. Describe how to appropriately communicate
advance care plans between team members
Introductions
• What is your professional role?
• ACP knowledge?
– advanced, intermediate, fresh
• What do you hope to get from today?
Setting the Stage
• http://www.pallium.ca/advance-careplanning-its-never-too-early-to-prepare/
What’s the context?
Advance care planning is a
process of reflection and
communication…to let others
know your future health and
personal care preferences...
(www.advancecareplanning.ca)
At time of death:
42.5% require decision-making
70.3% lack capacity
(Silveira et al. NEJM 2010; 362:1211)
Care Consistent with Patient
Values and Goals
www.thecarenet.ca
Advance Care
Planning
• Conversations about values,
wishes & preferences
• Appointment of a Substitute
Decision Maker
• Development of Advance
Care Plans and Instructional
directive (where applicable)
• Advance care planning
documents
• Goals of care documents
(MOST, POLST, other
level of care forms, etc.)
• Care Plans
Decisions about Goals of Care
or consent* for treatment
• Clarification of previous ACP
conversations; values; preferences
• Information re Diagnosis;
Prognosis; Risks/benefits of
treatment
• Options for care & treatment
Documentation
Organizational and System Aspects (context specific)
Home or Community
Settings
Institutionalized Settings
National ACP Framework
Few people know what we are talking about!
CHPCA- National Ipsos Reid Poll 2012
In your opinion, how important is it to discuss one’s end-of-life care with…?
% Total
(Ex/V.
important)
% Had
Discussion
Family
member
83%
34%
Health care
provider
51%
5%
Friend
40%
11%
Lawyer
36%
7%
Financial
advisor
29%
5%
CHPCAHarris Decima Poll (n=2,976) 2013
What about older patients?
Advance care planning evaluation in sick, elderly
patients (ACCEPT Study)
75% participants have thought about care they want
90% discussed with family
55% discussed with a health care provider
30% discussed with lawyer
20% recall being informed of their prognosis
Heyland et al JAMA Int Med
2013 ; 173
In-hospital goals of care discussions
From Dr John You, ACCEPT
Conversation element (patients n=233)
Occurrence (%)
Importance ranking
Asked about prior discussions or written documents
23.8
7
Gave opportunity to express fears or concerns
22.5
4
Asked about preferences for care in event of life-threatening illness
21.5
1
Asked if they had additional questions about goals of care
19.9
5
Inquired about respondent’s values
16.3
2
Provided information about outcomes, risks, benefits of life sustaining
treatments
12.4
9
Provided information about outcomes, risks, benefits of comfort care
9.9
6
Discussed prognosis
9.8
3
Offered a time to meet to discuss goals of care
6.3
8
Provided information to review about ACP prior to discussions
3.5
10
Helped access legal documents to document advance care plans
1.4
11
I didn't know what he (doctor) was saying when
asking me when I was in the ER. “Do I want
CPR?” He asked with no explanation. I said
“sure if it works.’ He put down YES on the
form, but then told me it probably wouldn't
work and I would have brain function problems.
Good God! I don't want that! Give the
information first, then ask the question!
(Patient)
What’s the impact?
Lack of concordance: patient preference & orders
Heyland et al JAMA Int Med 2013 ; 173
Unsure
Mixed
• only 30.2% raw agreement
• Greatest discordance: 28% preferred
comfort measures, but only 4.5%
documented as such
Documents
Comfort
Preferences
Full but no
CPR
Full Code
0
20
40
Contextual factors influencing ACP uptake
Systematic review (Lovell Pall Med 2014)
• Age
• Disease (cancer>non-cancer, renal>COPD)
• Physical function
• Ethnicity/Culture
• Previous illness experiences (self/others +/-)
• Personal attitude (relieve burden, conflict, control)
• Avoidance of taboo topic
• Concerns about formalized plans
What patients are telling us
BMJ Supp Pall Care Simon 2013- ACCEPT Data
‘I don’t have a problem talking about this; life is life;
you need to take it as it comes.’
‘I don’t like to think about dying. I guess if he asked I
would talk about it.’
‘Why should I talk with the doctor when family all know
my wishes?’
No need to, because I was in good health. I am 83, but
slowing down and still playing golf. It hasn’t been a
priority.’
Objective 1:
• Describe the role of various health care
providers in initiating, continuing and
facilitating advance care planning
conversations.
Which organizations should be driving
ACP in Canada?
Sally is living at home
Sally is a 74 year woman of Chinese descent.
Married, has 4 children. Sally has severe
hypertension that is barely managed by 3 oral
medications. Her renal function is poor.
• Where would Sally learn about ACP?
• Which healthcare professionals might discuss ACP
with Sally?
Nurse
Social Worker
Physician
Others on the team
•
•
•
•
•
•
•
Dietician, Respiratory Therapist
Nursing aide/personal care aides
Occupational Therapist
Spiritual Care Practitioner
Pharmacist
Adminstartive leaders
Volunteers
How do we work together?
• Overcoming Challenges
– Fluctuating Team Membership
– Differences of opinions
– Working with clinicians outside your setting
Objective 2:
• Identify the optimal topics to include in ACP
conversations based on the health status of
the individual involved.
Sally is living at home
Sally is a 74 year woman of Chinese descent.
She is married and has 4 children. Sally has
severe hypertension that is barely managed by
3 oral medications. Her renal function is poor.
• What topics should be covered with Sally?
Atul Gawande’s topic tips
https://www.youtube.com/w
atch?v=45b2QZxDd_o
Patient’s preferences for communication
•
•
•
•
“Know me first”
“Conditional Candour”
“Just Ask!”
Non-verbal behaviours
Dr Amane Abdul Razzak 2013, in submission
Sally is in the hospital
Sally has been admitted with nausea and
abdominal pain. She has developed further
cardiac complications. Her spouse and 3 of her
children are visiting regularly.
What core elements could/should be addressed
with Sally?
What health care professionals could/should be
completing these core elements?
Sally is deteriorating and is in delirium
• Are you looking for documentation about
ACP? Where?
• Are you talking with other health care
professionals? Who?
• Are you talking with family members? Who?
About what?
• Would the team’s actions change if there was
an appointed proxy (substitute decision
maker)?
• Would the teams actions change if there was
an instructional (advance) directive?
Tools & Resources - Fraser Health
• www.fraserhealth.ca/professionals/advancecare-planning/
• Core Elements of ACP conversations
• SPEAK
Tools & Resources - National
• www.advancecareplanning.ca
– training powerpoints/facilitators guides on ACP
and Consent & Capacity (ON)
– Primary Care Toolkit
– videos
Tools & Resources - Alberta Health Services
www.conversationsmatter.ca
Let’s take a break
Objective 3:
• Acquire skills for initiating and continuing
advance care planning conversations.
‘I like a doctor I can talk to that will listen to
another person’s views, that will talk to me with
good bedside manner, some don’t feel
comfortable talking about it.
Some Options for this session
• Education Evidence? (Role Play, videos)
• Theory (Ask, Tell, Ask) (Ask, Listen, Ask)
Conversationsmatter workshop video clip
Case Based Exercises
• In groups of three
• Rotate being Person, Family member, Clinician
Reflections
• What feelings did you experience as you
played the role of the patient?
Reflections
In the clinician role, what surprised you?
Reflections
• As a family member what did you observe?
Objective 4:
• Describe how to communicate advance care
plans and conversations between team
members and between health care sectors
and the public
What’s happening in your organization?
• How you would summarize your conversation
in written form
• Where you would write this
• How would your health care team members
communicate toghether to care for this
person?
Communication Strategies
• Person ownership
• Greensleeve(s)
• Use of ACP Record
Where should ACP info to live?
• Person ownership?
- electronic/paper
• Health record systems?
– electronic/paper
Case study - Fraser Health
• Mixed electronic and paper environment
How does that compare to your area?
Advocacy in action
• What are the key elements of a public
engagement campaign?
• What can each of us/our organizations do to
promote shift in culture, skills and attitudes of
Health Care Providers for high quality ACP?
Summary
Contact
Louise Hanvey, RN, BN, MHA
Director, Advance Care Planning in Canada
[email protected]
Contact
Cari Borenko Hoffmann, RSW
Project Implementation Coordinator
Fraser Health, British Columbia
(604) 587-4408
[email protected]
Contact
Dr Jessica Simon
Physician Consultant, Advance Care Planning
and Goals of Care, Calgary Zone, Alberta
Health Services
[email protected]
Thank You!