Transcript Advance Care Planning Service

AIMS
• The Prince of Wales Hospital Service
• NSW Health initiatives
Advance Care Planning
Service
• Since 2001
• 1 CNC
• Started with Nursing Home residents &
their families & GPs
• Discussion re treatments & care regarding
end of life issues
• Who wants to document an ACD?
• Not 2-3 days, (usually 1-2 years)
The NSW Context
• Consent
– Practitioners require a valid consent
– Capable Patients have the right to refuse treatment
– The Guardianship Act (1987) provides a mechanism for
substitute consent for those who lack capacity to give a valid
consent
• NSW Health
– Using Advance Care Directives (June 04)
– Guidelines for EOL care and decision-making Mar 05
– NSW Health Circular 2004/84/ Consent (Dec 04)
Circular PD2005_406 or 2004/84 is MANDATORY POLICY
Documentation Standards
1.
2.
3.
4.
Specificity
Currency
Witness
Capacity
1. It needs to apply to the clinical
situation that has arisen
2. Does it reflect the current
(known) wishes of the
patient?
3. Has the witness verified that it
was completed voluntarily
4. Assume capacity unless a
valid trigger otherwise
If any of these criteria not met, it
may be set aside.
POWH Project
1.Education
•
Inservices to staff on Consent,
Substitute Decision Making and how
advance care directives may apply:
– RACF, Hospital & Community Health staff,
– GPs at RACF mtgs, - via Divisions, interest
groups
– Families via relatives mtgs in RACFs
The POWH Project
• Large % High level Care residents lack
capacity ~ 80%
• ?Involve Proxies/ Pers Resp
– Volicer et al 2002 (JAGS 50:761-767)
– Karlawish et al 1999 (Annals Int Med.
V130 N10)
• Guardianship Tribunal (previously)
agreed Pers Resp can complete a Plan
of Care (not an ACD!)
2. An Organisational
Approach
RESIDENTIAL CARE
– Identify Person Responsible on admission
– Case conference (4-6/52 following
admission) raise Question re ACD?
– Invite resident/ relative for more info
– Document ACD or Plan of Care
– Policy to support ACP Process
2.Clinical Care
• Hospital - Follow up referrals from:
– ED, Inpatient wards (POWH & SVH); Post Acute Care &
Palliative Care Services
• Residential– Identify residents at end stage (primarily dementia):
– Discussion & Documentation of ACDs or Plans of Care.
Focus on what can be done!
– Resident may still require transfer to hospital for
diagnosis/symptom management if GP unavailable
• Community:
– Case managers/GPs identify those wishing to explore
issues further
In reality….
• The majority of people with advancing
dementia have never thought about what
care and treatment they may want/not
want & at what point………….
• as the disease progresses, they may lose
the ability to discuss what is important to
them or consider treatment options…
MILD
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D
E
P
E
N
D
E
N
C
E
MODERATE
MEMORY
PERSONALITY
SPATIAL
DISORIENTATION
APHASIA
APRAXIA
CONFUSION
AGITATION
INSOMNIA
SEVERE TERMINAL
RESISTIVENESS
INCONTINENCE
EATING
DIFFICULTIES
MOTOR
IMPAIRMENT
BEDFAST
MUTE
DYSPHAGIA
INTERCURRENT
INFECTIONS
TIME
MILD
C
A
P
A
C
I
T
Y
MODERATE
MEMORY
CLINICS
Consider
Subs. Dec-maker
EPOA
P/R
E/G
Discuss?
ACD
SEVERE TERMINAL
GREY AREA
Fluctuating levels of confusion
? Depression, delirium
Reverse what is
reversible Review when
stable
Give best opportunity for
promoting capacity and ability,
environment to provide input into
their own care & wishes
Shared decision-making/ values
TIME
Plan of Care
for those incapable
Of consent
Decisions, Decisions…
• The decisions will fall to the “person/s
responsible”
• Forewarned is forearmed
• This discussion is never easy
• Especially in an emergency!
• But questions will be asked
• Either on admission to services, aged
care facilities, or, in Emergency Dept,
when you least expect it….
Plan of Care
• Where a patient/resident is incapable of
discussing their healthcare wishes, the family,
or more importantly, the “person responsible”
can indicate in a Plan of Care the aims and
levels of care they consider would be
appropriate,
• This is done with facility staff and the via
discussion with the GP.
• Other consultations/opinions may be sought.
• The Plan outlines the aims of care and provides
a good foundation for future treatment based on
the evidence and current individual situation.
• When a patient/ resident becomes ill, the staff
are aware of what the expectations are, in the
context of current situation (symptoms).
• Options for treatment within the facility are noted
• Facility staff involved
• ED staff aware
• Consent may still be required for specifics
CPR / No CPR
• CPR
– Use cardiac massage with mouth to mouth
breathing; may also include
– Intravenous lines & drugs
– electric shocks to the heart defibrillators),
– tubes in throat to lungs (endotracheal tubes)
• No CPR
– make no attempt to resuscitate, & you will die
However!……CPR
• In hospital, overall CPR successful (to
discharge from hospital) = 13% of pts
treated (1)
• Pts living in long-term care (800),
– success rate (admission to hospital alive) 143,
(on average <18 %, - range 8.9 - 40% )
– survival rate (discharge from hospital alive) 27 (on
average < 4% {800} - range 0-10.5%)(2)
1.Ebell et al J Gen Intern Med.1998;13:805-816
2. Finucane & Harper J Am Ger Society 1999;47:1261-1264
Reversible or Irreversible?
Reversible
• A life threatening
illness or injury that
is curable, meaning
that losses in my
ability to function are
not permanent
Irreversible
• The condition is likely
to leave you an
irreversible permanent
disability or decrease in
function
• Each of us would
accept different
irreversible disabilities
• Discuss with Dr and
other relevant people
ie, family, religious and
cultural leaders
Levels of Care
•
•
•
•
Palliative/ Comfort
Limited
Active
Intensive
Palliative/ Comfort
• Free from pain & discomfort as much as
possible
• Any treatments or investigations will be for
the purpose of enhancing comfort or
minimizing pain
• Analgesia
• this may include surgery (ie, to relieve pain
following fracture)
Limited
• = Palliative, plus
•
•
•
•
•
•
May include transfer to hospital as required
Intravenous therapy (I.V or drip)
Antibiotics
Trial of appropriate drugs
blood- transfusions, tests, cross-matching
non-invasive investigations & treatments
(short of elective surgery)
• No elective surgery except for pain relief
Surgical/Active
• = Limited, plus
• transfer to hospital for evaluation
• gastroscopy, endoscopy, colonoscopy (all
investigations) & surgery (if necessary)
• ventilation for the purposes of
anaesthesia/ surgery may be included
Intensive
• = Surgical/Active, plus
• Transfer to hospital without hesitation
• all possible treatments in a large
modern hospital
• Admit to ICU if necessary
• all options, ventilation, central venous
lines, monitoring, transplants, dialysis
• do everything possible to maintain life
What are the advantages
and disadvantages of going
to hospital for treatment as
opposed to staying at home
or in the aged care facility?
Transfer to Acute Care
• Secure environment ‘v’ elopement risk
– Restraint may be required
• Tests well tolerated if cognitively intact
– Confused pt becomes anxious +/- combative
• +/- additional treatment following diagnosis
– Leading to complications, therefore restraint
required: decrease in mobility, pressure areas,
incontinence & hasten functional decline in
vulnerable pt (3)
3.Applebaum et al J Am Ger Society 1990;38;197-200
So what are the alternatives?
• Geriatrician visit
• Post Acute Care or Hospital outreach
service
• Palliative Care
Depends on knowledge of local services and
what is available
Feeding
• Basic & Supplemental (self explanatory)
• Intravenous
• Tube
Tube
• Tube feeding. There are two main types:
– Nasogastric Tube a soft plastic tube passed
through the nose or mouth into the stomach
– Gastrostomy Tube a soft plastic tube passed
directly into the stomach through the skin
Feeding tubes
• Nasogastric may be beneficial in the short
term
• But confused patients often pull them out!
• They are uncomfortable
• It could be the patient way of telling us
they have had enough or are objecting
• Dilemma ….
MEAN DISCOMFORT RATING (1-10)
(n=100)
Nasogastric tube
Mechanical ventilation
Mechanical restraints
Indwelling urethral catheter
Phlebotomy
I.M. or S.C. injection
Movement from bed to chair
Morrison et al. J.Pain Sympt.Manag.15,91,1998
8.8+1.9
8.0+5.4
7.8+3.2
6.2+2.9
3.6+2.6
3.5+2.7
2.6+2.6
PEG Tubes & advanced
dementia
•
•
•
•
1996-1999 meta-analysis
Prevent aspiration pneumonia?
Prolong survival?
Reduce risk of pressure sores or
infections?
• Improve function?
• Provide palliation?
Finucane T et al, Tube feeding in patients with advanced Dementia:
a review of the evidence JAMA Vol 282(14),1991 pp267-274
What is a Palliative Approach?
• Focus on care by maximising function & Quality of Life
• Minimise all negative factors
– Anticipate complications (such as aspiration pneumonia)
– Manage symptoms (HITH or Palliative Care)
•
•
•
•
Maximise positive factors
Enjoyment~
Namaste (Simard)
Sensory stimulation
–
–
–
–
Massage/ Aromatherapy
Music
Simulated presence
Taste
• You don’t need to wait until the 11th hour to adopt it!
Guidelines for a Palliative Approach in Residential Aged Care 2004. DoHA
NSW Health Initiative
• Advance Care Planning in residential care
• 0.6 FTE per Area Health Service to assist
residential care by fine tuning processes,
improve partnerships between acute and
residential, palliative care and general
practice
Caplan et al Age and Ageing 2006; 35: 581–585
So at your leisure…
• Identify -Who would be your ‘person
responsible’? (Sheet 1)
• According to GT hierarchy,
• Is there a need to appoint an E/Guardian?
• Have you discussed issues and wishes with
them? What’s important?
• What would be an intolerable functional
situation….this can be difficult to define.
• Then…
• Consider documenting an ACD
Sheet 2 -Consider each of the responsibilities listed in the left
hand column, and write down the names of three possible
spokespersons you feel are well qualified to act for you in this
way
Names of Possible Spokespersons
Name 1
Would be willing to speak on my behalf
Would be able to act on my wishes and separate his/her
own feelings from mine.
Lives close by or could travel to be at my side if needed
Knows me well and understands what’s important to
me.
Could handle the responsibility.
Will talk with now about sensitive issues and will listen
to my wishes.
Will be available in the future if needed
Would be able to handle conflicting opinions between
family members, friends and/or medical personnel
Name 2
Name 3
Tools
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My Health, My Future, My Choice:
Let Me Decide
Law Society of NSW
Planning My Future Medical Care (Catholic
Healthcare)
Colleen Cartwright (Lismore)
Hard choices for loving people (Hank Dunn)
planningwhatiwant.com.au
Respectingpatientchoices.org.au
Contact Details
• Anne Meller 9382 2984 (voicemail)
– [email protected]