Transcript Advance Care Planning Community Experiences in N Ireland

Advance Care Planning
Community Experiences in N Ireland
Dr Graeme M Crawford
Macmillan GP Facilitator, N Down & Ards
Outline
•
•
•
•
•
Primary Care in N Ireland
Strategies
GSF & LCP
Common practices
Limitations & Challenges
Primary Care Team
• GP
• District Nurse - Key Worker
- member of Palliative Care
Link Nurse group
- Rapid Response Nursing
- 24 hour nursing
Occupational Therapist
Physiotherapist
Social Worker
Community Pharmacist
Community Palliative Care Team
Marie Curie Night Service
NI Hospice Home Nursing Service
Nursing Homes
Community Hospital beds
Hospice including Day Hospice
Community Palliative Care Team
Consultant
Macmillan GP Facilitator
Palliative Care Nurse Specialists
Specialist: OT, Physiotherapist, SLT, Dietician
(support healthcare professionals; clinical input complex palliative
patients; training & education)
GP Contract - Cancer
• Practice holds register of all cancer
patients
• Cancer patients reviewed within 6
months of diagnosis
GP Contract – Palliative Care
• Practice register of all patients in need of
palliative care
• Practice holds multidisciplinary case review
of all patients on palliative care register
Priorities for Action 2009/10
Ensuring Fully Integrated Care &
Support in the Community
Palliative care
“by March 2011, Trusts should establish multidisciplinary palliative care teams and supporting
service improvement programmes, to provide
appropriate palliative care in the community to
adult patients who require such services”
PfA promotes
•
•
•
•
•
multidisciplinary teams
24 hour care in the community
use of GSF & LCP
education standards
has lead to Trusts employing
Service Improvement Leads
Living Matters, Dying Matters
A Palliative and End of Life Care Strategy
for Adults in N Ireland, March 2010
“all palliative and end of life care is planned
around the assessed needs of the individual...and
is responsive to their expressed preferences”
Recommendations
• 17. Timely holistic assessment by a MDT undertaken
…to ensure their needs are identified, recorded,
addressed and reviewed.
• 22.Policies should be in place in respect of advance care
planning.
• 23. Tools such as GSF, Preferred Priorities of Care,
Macmillan Out-of-Hours Toolkit or LCP should be
embedded into practice across all care settings with
ongoing facilitation.
Gold Standards Framework
•
Focuses on optimising continuity of care;
teamwork; advance planning ( including
out of hours); symptom control; patient ,
carer & staff support.
•
Developed for use in Primary Care ; can
be used in Care Homes and all disease
groups.
Gold Standards Framework
• Identify patients in need of supportive/
palliative care
• Assess their needs and preferences
• Plan their care, enabling patient to live and
die where they choose
• Communicate across relevant agencies
GSF Prognostic Indicator Guidanceidentifying patients with advanced disease in need of
palliative/ supportive care/for register
Three triggers
1.
Surprise question would you be surprised if the pt
was to die within 1 year?
2.
Patient preference for comfort care/need
3.
Clinical indicators for each disease area eg cancer
metastases , NY stage, FEV1,
Performance status
GSF Care Homes
• Improved quality of care
• Improved communication with residents
and families
• Reduced crises
• Hospital admissions reduced by 12%
• Hospital deaths reduced by 8%
Liverpool Care Pathway
Useful template to guide the delivery of care in the
last days of life, making quality of care measurable
and explicit.
•
•
•
•
•
Symptom control
Comfort measures
Anticipatory prescribing
Discussion about inappropriate interventions
Care for the family
GPs are ideally placed for ACP
• Aware of the anticipated deterioration in the individual’s
condition .
• Should include - our patient’s understanding of their
illness and prognosis
- their preferences for care
• Should be
- documented
- regularly reviewed
- communicated to key persons involved
in their patient’s care ( GP and nursing
notes, OOH, Ambulance Service)
Prognostication
• “Would I be surprised if my patient died in the
next 12 months?”
• new diagnosis of a life-limiting condition
• deteriorating prognostic indicators
• steep change in treatment
• multiple hospital admissions
• admission to a care home
• when a thorough reassessment of the patient’s
needs is required
• death of a spouse or carer
Mr B’s experience
- Reactive Patient Journey
• GP & DN’s have ad hoc arrangements; no plans
discussed or communicated
• Problems with symptom control
• Carers struggling to cope
• No life closure discussions, DS1500 forms etc
• Crisis call eg OOH – no management plan, drugs
or equipment
• “999” admission via A&E
• Dies in hospital – over medicalised / interventions
In practice…..
•
•
•
•
•
•
Diagnosis
Register
Monthly Practice MDT meeting
Out of Hours Handover form
Anticipatory planning / prescribing
Liverpool Care Pathway
Mrs W’s Experience
- Proactive Patient Journey
• On Palliative Care Register: discussed at team
meeting
• DS1500 form and information given to patient and
carers
• Regular support, visits/phone conversations
• Assessment of symptoms
• Preferred place of care noted and organised
• Handover form
• Medication and equipment
• Patient dies in preferred place
• Bereavement support. Staff reflection: SEA’s
Limitations
(Telephone survey of GPs in Scotland & NI)
• no real consensus about the terms but most
people doing roughly the same thing.
• no set Advance Care Planning
documentation.
• most GP explicity linked ACP to cancer.
• policies are only an impressionistic
induction.
• has improved communication.
Limitations
•
•
•
•
•
•
•
•
late identification of patients
difficulties with continuity of care
Out of Hours care
variations in skills/ experience/ interest of
practitioners
wide variations in the levels of social & nursing
support in Primary Care
lack of timely interventions when situations
deteriorate
poor documentation ( NI Cancer Registry)
Nursing Homes
Challenges
• Prognostication - Secondary Care to
identify and communicate to Primary Care
those patients in palliative phase
• Goal setting
• Documentation
• Communication
• MAKING TIME
How well do we do?
• Understanding our patient’s illness &
prognosis ( good)
• Concerns & wishes identified ( reasonable)
• Important values & personal goals for care
(poor)
• Eliciting preferences for types of care and
treatment ( reasonable)
websites
ACP www.endoflifecareforadults.nhs.uk
GSF www.goldstandardsframework.nhs.uk
LCP www.liv.ac.uk/mcpil/liverpool-carepathway/index.htm
Macmillan Toolkit www.macmillan.org.uk/learnzone