advance care planning...advance care planning is the process through which people make decisions...
TRANSCRIPT
Advance Care Planning
What is the answer?
What is the question?
Lots of controversy surrounds ACPLegality
Morality
Functionality
Economy
Efficacy
What is an ACP ?
Advance care planning is the process through which people make decisions about their future care in the event of them losing their decision making capacity.
It is done in consultation with clinicians, family members and significant others
It primarily involves having discussions about future care choices and wishes
Advance care planning is a process, not a task
Patient & Family
• Patient centred care
• Improves patient and family satisfaction
• Reduced stress anxiety and depression in surviving relatives
Health professional
• Patient centred care
• Assists with end of life care planning and treatment options
Organisation and System
• Reduced hospitalisations
• Reduced financial burden on acute care facilities
• Quality Improvement Payment
Advance care plans are tools in the advance care planning process:
Acute Resuscitation Plan Advance Care Plan Advance Health Directive
What are the legal implications ?
What is Capacity
’ is the ability to: understand the nature and effect of decisions about a matter freely and voluntarily make decisions about the matter, and communicate the decisions in some way.
The decision-making capacity of an adult may differ according to: a. The nature and extent of the impairment; and b. The type of the decision to be made, including, for example, the
complexity of the decision to be made; and c. The support available from members of the adult’s existing support
network
Decision-making hierarchy in Queensland:
1. The patient’s valid Advance Health DirectiveSu
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2. QCAT-appointed Guardian
3. Enduring Power of Attorney
4. Statutory Health Attorney
5. The Public Guardian
Acute Resuscitation Plan
Developed to replace NFR orders
Implemented in 2011
ARP is an advance care planning tool
If you are considering an ARP for a patient, the patient should be offered an advance care planning discussion
Advance Health Directive
24 page document
Legally binding document (in most circumstances)
AHD has some formal requirements
Has a ‘tick box’ approach to end of life planning
Very specific choices in very specific circumstances
Advance Care Plan
No legally binding decisions – choices NOT decisions
Documents end of life wishes and preferences of patient
https://metrosouth.health.qld.gov.au/acp
The minimum and mandatory elements of the SoC required to be completed prior to upload to The Viewer include
1.personal details 2.current health conditions (Form A) or current medical conditions
(Form B) 3.life prolonging treatment preferences 4.signed and dated declaration 5.substitute decision maker/s contact details 6.signed and dated Doctor’s review of plan.
Who should have one?
Who should have one?
Acute hospitals General Practice Residential aged care
• Patients who live in (and transferred to hospital from) a RACF who do not currently have an advance care plan in place
• Patients who are being discharged to a RACF who do not currently have an advance care plan in place
• Patients who meet the SPICT Tool criteria
• Patients who meet the SPICT Tool criteria
• Patients who live in a RACF who do not currently have an advance care plan in place
• All residents who meet the SPICT Tool criteria
When should it be done ?
Supportive and Palliative Care Indicators Tool:
Would you be surprised if this patient dies in the next 12 months?
2 or more indicators of deteriorating health
Any clinical indicators of advanced conditions
For further information go to www.spict.org.uk
Ref: Highet G, Crawford D, Murray SA, Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): A mixed methods study.BMJ Supportive & Palliative Care. Published online First: 25 July 2013
Doi:10.1136/bmjspcare-2013-000488
SPICT?
Look for any general indicators of poor or deteriorating health.
Unplanned hospital admission(s). Performance status is poor or deteriorating, with limited reversibility.(eg. The person
stays in bed or in a chair for more than half the day.) Depends on others for care due to increasing physical and/or mental health
problems. The person’s carer needs more help and support. The person has had significant weight loss over the last few months, or remains
underweight. Persistent symptoms despite optimal treatment of underlying condition(s). The person (or family) asks for palliative care; chooses to reduce, stop or not have
treatment; or wishes to focus on quality of life
Cancer
Functional ability deteriorating due to progressive cancer.
Too frail for cancer treatment or treatment is for symptom control.
Dementia/ frailty
Unable to dress, walk or eat without help.
Eating and drinking less; difficulty with swallowing.
Urinary and faecal incontinence.
Not able to communicate by speaking; little social interaction.
Frequent falls; fractured femur.
Recurrent febrile episodes or infections; aspiration pneumonia
Neurological disease
Progressive deterioration in physical and/or cognitive function despite optimal therapy.
Speech problems with increasing difficulty communicating and/or progressive difficulty with swallowing.
Recurrent aspiration pneumonia; breathless or respiratory failure.
Persistent paralysis after stroke with significant loss of function and ongoing disability
Heart/ vascular disease
Heart failure or extensive, untreatable coronary artery disease; with breathlessness or chest pain at rest or on minimal effort.
Severe, inoperable peripheral vascular disease.
Respiratory disease
Severe, chronic lung disease; with breathlessness at rest or on minimal effort between exacerbations.
Persistent hypoxia needing long term oxygen therapy.
Has needed ventilation for respiratory failure or ventilation is contraindicated
Kidney disease
Stage 4 or 5 chronic kidney disease (eGFR < 30ml/min) with deteriorating health.
Kidney failure complicating other life limiting conditions or treatments.
Stopping or not starting dialysis.
Liver disease
Cirrhosis with one or more complications in the past year: diuretic resistant ascites
hepatic encephalopathy
hepatorenal syndrome
bacterial peritonitis
recurrent variceal bleeds
Liver transplant is not possible.
Other conditions
Deteriorating and at risk of dying with other conditions or complications that are not reversible; any treatment available will have a poor outcome
Where should they keep it ?
The viewer
My Health Record
Relevant health professional
Carers
The fridge
Preparation for the ACP discussion:
Social setting Ensure privacy and quiet
Ask patient / SDM who they would like to be part of the discussion – facilitate as far as practicable
Ensure the HCP leading the discussion knows the patient
Check the patient is comfortable prior to session
Ensure enough time is allocated
Use interpreters' if required
Self preparation Read the chart, know the patient
and facts about treatment
Ask other HCPs what they have discussed with the patient
Mentally prepare for the meeting
How do you bill ?
Health assessmentCare Plan
How many are being done ?
Metro North HHS Advance Care Planning Activity July 2018 As at 31 July 2018, a total of 1773 Advance Care Planning (ACP) documents have been uploaded, by the Office of ACP
Statement of Choices Of the 1543 (10,816 QLD ) Statement of Choices (SoCs) which have been uploaded to The Viewer: • 74% are Form A 62%• 26% are Form B. 38%
Table 1: Number of completed SoCs (based on month signed), by sector, Metro North HHS, 2016-17 to 2018-19 Sector 16-17 17-18 18-19* Total Community 224 302 14 540 (40%) 2628 (30%)Hospital 250 325 6 581 3091RACF 71 158 <5 233 3044Total 545 785 24 1354 8763
How useful are they?
What you need to know
The Queensland Government is encouraging patients and the community to discuss their health care wishes with their doctor. Your patients may ask you about advance care planning in general or their Statement of Choices form in particular. The Statement of Choices provides you with another advance care planning tool which you can offer your patients. Form A and Form B includes a section for a Doctor's review and signature. The Statement of Choices is currently available in the majority of hospital and health services (HHSs) across Queensland and is
available to view in all Queensland public hospitals. If advance care planning is initiated with patients in the hospital setting, information will be included in the discharge
summary provided to the patient's GP listed in the medical record. We can now keep your patients’ Statement of Choices documents securely on file, so that they can be accessed if needed if
your patient comes to a Queensland public hospital. An alert on patient medical records has been established, so that hospital staff will be notified if the patient has commenced
advance care planning, and/or has completed documents. Copies of Statement of Choices documents provided to the Office of Advance Care Planning will be clinically audited and
uploaded to the patient's electronic medical record in The Viewer (a secure web-based application enabling access to key patient information). The Viewer application should also be available to GPs from mid-2017.
Hospital staff in your region will be notified and may place an alert in the public health medical record.
How to access the Statement of Choices form
An online writable PDF document can be downloaded from the My Care, My Choices website.
Printed forms and brochures are available upon request. To order printed versions of the form, please contact the Office of Advance Care Planning on phone 1300 007 227, fax 1300 008 227 or email [email protected]
The form will be integrated into the most commonly used GP Practice software packages as a template. (We will notify you when this is available)
What do I do if my patient asks about advance care planning?
1.Outline the process of advance care planning.
2.Provide the patient with the Advance Care Planning brochure (PDF, 838.76 KB).
3.Schedule a long appointment with your patient. Use the paper Statement of Choices form, or type their choices directly into the online PDF form ready to print and sign.
4.Suggest the patient complete their Enduring Power of Attorney to legally appoint their substitute decision maker(s).
5.Ask your patient to discuss their wishes and health care choices with their substitute decision maker(s), family and/or close friends.
6.Some patients may like to read the advance care planning documents ahead of time. Suggest your patient goes to My Care, My Choices website to access the documents online. You may choose to give the patient a copy of the Statement of Choices document (the Office of ACP can provide a supply of the Statement of Choices documents)
What do I do if my patient has completed a Statement of Choices?
1.Check the patient has read each section; discussed their preferences with their substitute decision maker(s), family and significant others; and written their choices on the correct form (Form A for people with decision-making capacity, Form B for people without decision-making capacity)
2.Clarify any questions the patient may have about their decisions.
3.Have the patient sign and date the declaration in their completed Statement of Choices form.
4.Ensure the correct contact information is provided for their substitute decision maker(s).
5.Complete the Doctor’s Review of Plan section (page 3 of 3).
6.Give the original document to the patient. Advise them to keep it in a safe but accessible place.
7.Keep a copy in your patient's file. Advise the patient to give photocopies to their substitute decision maker(s) and/or family and close friends.
8.Send a copy of their completed Statement of Choices document to the address details on the form (bottom of page 3) so it can be added into their secure electronic Queensland Health medical record.
Don’t offer what is not appropriate
Who should do it ?
Discussion
Where to from here?