advance care planning and goals of care at royal melbourne …€¦ · facilitating advance care...

Advance Care Planning and Goals of Care at

Royal Melbourne Hospital

Rohit D’Costa: ICU Specialist and State Medical Director for Donatelife Victoria

Jo Slee: Advance Care Planning Project Officer, Royal Melbourne Hospital

Overview

• Advance Care Planning at RMH

– Background

– Advance Care Planning in 3 Steps

• Goals of Care

– Background

– Implementation and evaluation

• A process of planning for future health

care and personal care needs

• A person’s values, beliefs and preferences

are made known

• A guide for future decision-making, if the

person cannot speak for themselves

Advance Care Planning

• People live longer with chronic illness

• 54% of deaths occur in hospital despite a majority of people expressing a desire to die at home

• Up to 50% of deaths are clinically expected

• People are often unable to speak for themselves when medical decisions need to be made

• Few families have discussed end of life issues in-depth

• Many patients receive care that is inappropriate or

futile at the end of their life

Why is ACP so important?

AIHW 2012, ABS 2012, Bloomer et al 2010, Scott et al 2013, Swerissen and Duckett 2014

• Improved medical care

• Improved end of life care

• Improved patient and family satisfaction

• Less stress, anxiety and depression in the surviving

relatives

• Potential improvement in staff well being

• May act as a catalyst to improve communication

between cultures

• Reduce inappropriate transfers from residential aged

care facilities (RACF) to hospital

Benefits

Detering et al 2010, Riggs et al 2004, Caplan 2006, Sudore and Fried 2010

Providing opportunities for


is now an expectation

• National Safety and Quality Health Service

Standards (NQHSS)

• Federal Government – National Framework

• Victorian Department of Health

– ACP Strategy 2014-18

– Statement of Priorities

EQuIPNational – Advance Care Planning

Standard 1 – Governance for Safety and Quality in Health Service Organisations

1.18 Implementing processes to enable partnerships

with patients in decisions about their care, including

informed consent to treatment

1.18.1 Patients and carers are partners in the

planning for their treatment

1.18.4 Patients and carers are supported to

document clear advance care directives and/or

treatment-limiting orders

Standard 9 – Recognising & Responding to Clinical Deterioration in Acute Health Care

9.8 Ensuring that information about advance care

plans and treatment limiting orders is in the patient

clinical record, where appropriate

9.8.1 A system is in place for preparing and/or

receiving advance care plans in partnership with

patients, families and carers

9.8.2 Advance care plans and other treatment-

limiting orders are documented in the patient clinical

record

Standard 12 – Provision of Care

Criterion 4 The care of dying and deceased

consumers / patients is managed with dignity and

comfort, and family and carers are supported

Advance Care Planning and treatment limiting

orders are included in:

• organisation- wide policies/procedures and

systems for end of life care

• ongoing professional development for staff

AIMS • Promote ACP in the community

• Standardised approach/lexicon

• Increase transferability of ACP

across Australian states

• ACP a routine part of care

• Health care consistent with

patient’s expressed values and

preferred outcomes

Advance care planning: have the

conversation. A strategy for Victorian

health services 2014-2018

Four priority action areas: 1. Establishing robust systems so that

organisations can have the conversation.

2. Ensuring an evidence-based and quality

approach to having the conversation.

3. Increasing workforce capability to have the

conversation.

4. Enabling the person being cared for to have

the conversation.

Department of Health and Human Services (DHHS) Victoria

Facilitating advance care planning across the health and disease spectrum

Who can have an ACP?

• Anyone over the age of 18

• Particularly relevant for some patient groups

– People with life-limiting conditions

– Older people admitted to hospital with an acute

medical or surgical condition

– Anyone for whom you would answer “No” to

“Would I be surprised if this person died within 12 months?”

Cancer COPD Cirrhosis CCF CKD Dementia and other

Neurodegenerative disorders

Source http://www.cmaj.ca/content/early/2013/07/15/cmaj.121274.extract#

http://www.cmaj.ca/content/early/2013/07/15/cmaj.121274.extract

ADVANCE CARE PLANNING IN 3 STEPS

Appoint an agent

Communicate your wishes

Put it on Paper

APPOINT AN AGENT

Appoint an Agent

The competent patient can:

• Consent to or refuse treatment

For the non-competent patient:

• an Enduring Power of Attorney –

Medical Treatment (MEPOA) can

consent to or refuse treatment on the

patient’s behalf

OR

• The Person Responsible can consent

to treatment on the patient’s behalf

*Ask patients if they have a Medical Enduring

Power of Attorney and make sure this is

clearly documented in their medical history

COMMUNICATE YOUR WISHES

Communicate your wishes

*Encourage the patient to speak with their

Substitute Decision Maker, family and

health care team about

• Their values and beliefs

• Future situations they would find

unacceptable or too burdensome

in relation to their health

• Specific treatments that they have

said they would NOT want

considered

• Who they said they would like to

be involved in medical decisions

• Their current and future health care

needs

PUT IT ON PAPER

Put it on Paper

*Ask if the patient has written down their

wishes and ask to see the document/s.

This may include:

• Refusal of Treatment Certificate

Legally binding

• Letter or Statement of Choices

Consider if:

• Intentions are clear

• Written wishes still current

• Apply to current situation

• Freely written

*Document your discussions in on Record of

Advance Care Planning Discussions form

RMH Statement of Choices

Refusal of

Treatment

Certificate

Record of

Advance Care

Planning

Discussions


Patient Information

Translated into

- Arabic

- Traditional Chinese

- Greek

- Italian

- Turkish

- Vietnamese

Available MH Intranet and

RMH internet

GOALS OF CARE

Voltaire (1694-1778)

“The role of the

physician is to

amuse the patient

whilst nature takes

its course”

What to offer?

• Availability of therapies

• Efficacy

– No requirement to offer futile treatment

• Risks/Burdens to patient

• Cost

• Patient expectations and desires

• Family expectations and desires

– Patient/Family cannot demand treatments

Goals of Care vs LOMT

LOMT form satisfactory but…

• Ad hoc process

• Patient and family complaints

• Only small proportion of patients with LOMT forms (?Appropriate)

• No where to document in the form a curative approach (assumed)

• ‘LOMT’ confusion with ‘Palliation’

Goals of Care

Brings together:

Person Centred Care


Raising awareness

Implementing prior-planning

Shared decision-making for potential clinical

deterioration

Medical Treatment Goals

Emergency Treatment Escalation (CPR/MET)

CPR/NFR decision-making

Heyland, D., et al., Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Internal Medicine, 2013. 173(9): p. 778-787.

Patient preferences Vs

prescribed goals of care

Audit showed only 30% agreement between patients’ expressed

preferences for end of life care and documentation in the medical record.

Patients tended to express a preference for less aggressive care than that

prescribed. Similar results for substitute decision-makers.

1 = no treatment limitations; 2 = no CPR; 3 = comfort measures; 4 = mix of options e.g. try to fix

problems but move to comfort care if not getting better; 5 = unsure

International experience with GOC

• United States

– Physician Orders for Life sustaining

treatment paradigm (POLST)

• United Kingdom

– Universal Form of Treatment Options

POLST

• USA

– State specific

– Legal standing

– For patients where

death would not be

unexpected in the

next year

Fritz Z, Malyon A, Frankau JM, Parker RA, Cohn S, et al. (2013) The Universal Form of Treatment Options (UFTO) as an Alternative

to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Orders: A Mixed Methods Evaluation of the Effects on Clinical

Practice and Patient Care. PLoS ONE 8(9): e70977. doi:10.1371/journal.pone.0070977

http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0070977

UF

TO


UFTO

“Control” Period

(DNACPR)

Introduction of UFTO and embedding

UFTO evaluation





Reduction of harms identified on

Global Trigger Tool (GTT)


Table 6. The frequency of each type of harm for trigger categories within UFTO and DNACPR

groups.






Australian experience

Royal Hobart

Form introduced 2011

• 6 month post implementation

audit

– 75% completion in Assessment

+ Planning Unit vs 34% NFR

completion 2 years prior to

form

•18 month 1-day Point prevalence

– 52% of in-patients (85% of

medical patients)

– All patients who died had a

form completed

The Northern Hospital

Form introduced 2012

• Increase in limitations being in

place prior to MET

(Nov 12 – Jun 14)

– Surgical patients: 8.2% to 20.7%

– Medical patients: 38.1% to 69.4%

• Fewer limitations initiated by MET

in medical patients:

– 3.4% vs 13.1%

Thomas R et al. MJA 2014 201 (8): 452-455 Dr B Hayes, personal communication 2014

Goals of Care

Step 1 and 2

• Identifies: the Agent/Person Responsible;

people involved in the decision; and any

previous advance care planning.

Goals of Care

A. Curative (for CPR and all life sustaining

treatments)

B. Curative or restorative but treatment

limitations apply

C. Primarily non burdensome treatment

and symptom management

D. Comfort during dying – terminal care

Step 4

• Decisions to limit treatment should be

discussed with Consultant responsible for the

patient (or their delegate)

GOC – uncertain goals

• If there is uncertainty, treatment goals should

default to a higher Goal of Care category.

Either:

i. ‘Category A. Goal of care is curative or

restorative - No limitation of treatment’

OR

ii. A Goal of Care Category that only has limits to

treatment that can be determined confidently

despite the patient’s uncertain clinical condition

Review / revise as more information becomes available

Medical treatment goals based on -

…then within those constraints

…leading to

i. A medical assessment and a medical

decision about what is possible

ii. A shared decision-making discussion between

clinician

and patient and/or Person Responsible

An agreed medical treatment plan including:

- Overall medical treatment goals and

- Specific emergency medical treatments/limitations

Implementation

• GOC form completed for all patients admitted to

RMH

– Within 24-48 hrs of admission

• An accessible summary of the agreed medical

goals of care

• Pro-active decision:

– general guidance about the ‘big-picture’ and medical

treatment that is appropriate

– specific instructions about CPR, Respond Blue and

MET Calls

Evaluation and monitoring

• Post-implementation audit – point in time, by ward

– Proportion of patients who have GOC form in file

• Proportion of forms fully/correctly completed

• Repeat audit of consecutive deaths

– Compare with 2011 LOMT data

• MET Call data available from Riskman

– Pre- and post-implementation of Goals of Care

• Treatment limitations initiated at MET call

• Length of stay prior to MET Call

• Australian Health Minister’s Advisory Council. A National Framework for Advance Care Directives.

Sept 2011 http://www.health.gov.au/internet/main/publishing.nsf/content/acp

• Advance Care Planning in 3 Steps (Copyright Northern Health 2009)

• Brimblecombe, C., et al., The Goals of Patient Care project: implementing a proactive approach to

patient-centred decision making. Internal Medicine Journal, 2014. 44(10): p. 961-966.

• Department of Health and Human Services. Advance care planning - have the conversation: A strategy

for Victorian health services 2014-2018 http://www.health.vic.gov.au/acp/strategy.htm

• Department of Health and Human Services. Frequently Asked Questions on Advance Care Planning.

http://www.health.vic.gov.au/acp/faq.htm

• Fritz, Z., et al., The Universal Form of Treatment Options (UFTO) as an Alternative to Do Not Attempt

Cardiopulmonary Resuscitation (DNACPR) Orders: A Mixed Methods Evaluation of the Effects on

Clinical Practice and Patient Care. PLoS ONE, 2013. 8(9): p. e70977.

• Heyland, D., et al., Failure to engage hospitalized elderly patients and their families in advance care

planning. JAMA Internal Medicine, 2013. 173(9): p. 778-787.

• Victorian Quality Council. The Next Steps Conversations on end of life.

http://docs2.health.vic.gov.au/docs/doc/The-Next-Steps:-Having-Conversations-on-Life-and-Death--

Education-and-Training-Manual-February-2012

• Swerissen H and Duckett S, 2014, Dying Well. Grattan Institute ISBN: 978-1-925015-61-4

http://grattan.edu.au/wp-content/uploads/2014/09/815-dying-well.pdf

References

http://www.health.gov.au/internet/main/publishing.nsf/content/acp

http://www.health.vic.gov.au/acp/strategy.htm

http://www.health.vic.gov.au/acp/faq.htm

http://docs2.health.vic.gov.au/docs/doc/The-Next-Steps:-Having-Conversations-on-Life-and-Death--Education-and-Training-Manual-February-2012




































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