advance care planning...advance care planning is the process through which people make decisions...

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

Presenter

Presentation Notes

Advance care planning is a process not a task. Examples of advance care plans in Queensland Health are: The Acute Resuscitation Plan (ARP) The Advance Care Plan (ACP) Advance Health Directives (AHD) More on these later……

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

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Presentation Notes

AHD: AHD has to be a valid and signed original or certified copy. If AHD gives directions about specific medical circumstances where decisions are required AND is consistent with good medical practice, it is the legal decision maker for the patient. QCAT appointed Guardian: Queensland Civil and Administrative Tribunal may have appointed a legal guardian who becomes the decision maker EPOA If an EPOA for health matters has been appointed they become the substitute decision maker. Must see a valid, signed original or certified copy of the EPOA document Statutory Health Attorney: This somebody who has a close and continuing relationship with the resident. It may be a spouse, close relation, unpaid carer, friend etc.) The Public Guardian (formally the Adult Guardian): This is the last resort when there is nobody else to be called. Public Guardian makes specific decisions based on the medical need at the time.

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

Presenter

Presentation Notes

The intent of the ARP was not to change clinical practice but rather to change how and where it was documented and to ensure consistent documentation across Queensland health facilities The ARP is consistently used across Queensland health facilities If you are doing an ARP with a patient, they should be having an ACP discussion which may lead to an Advance Care Plan (the form!)

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

Presenter

Presentation Notes

Invoked when person loses capacity to make decisions AHD has some formal requirements: In writing Signed by person Witnessed by an eligible witness Contain a statement by the witness that he / she has seen the person execute the document and is satisfied person has capacity to do so Include a certificate signed by a health practitioner that the person signed the document in presence of the witness and that he / she is happy that person has capacity to sign the document Example of choices: I do / do not want artificial nutrition I do / do not want assisted ventilation Suggest that most families do not need an AHD. AHDs are useful for those who: Have very strong opinions about their choices and want them followed to the letter Do not trust family / potential statutory health attorneys to make good decisions in line with their wishes Who have no family or potential statutory health attorney

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

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Presentation Notes

Invoked when person loses capacity to make decisions Can be done with the statutory health attorney if the patient has lost capacity Not legally binding but can be a guide for the decision-maker when the time comes for them to make decisions AHD is for people who want to make decisions about future care needs NOW. ACP is for people who want to talk about their preference and choices

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

Presenter

Presentation Notes

Go through the criteria Will cover the SPICT in the next slide

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

Presenter

Presentation Notes

SPICT is a guide to identifying people at risk of deteriorating and dying Often used in conjunction with the ‘surprise question’ – would you be surprised if this patient dies in the next 12 months? SPICT aids clinical decision-making by multidisciplinary teams caring for patients with advanced conditions who are at risk of dying SPICT is not designed to identify patients for specialist palliative care referral

http://www.spict.org.uk/

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

Presenter

Presentation Notes

Social setting: Limit interruptions from pages, phones etc. – consider leaving them outside or switched to silent Make sure the people who need to be there are there without diluting the discussion with too many people The HCP must be able to answer questions about the patient’s condition and future disease trajectory. The HCP should be senior enough to do this whilst also knowing the case notes Give pain relief if required / ensure the environment is suitable (temperature, seating etc.) Make sure you allocate at least 20 minutes. Need to give patients and families time to ask questions. May need to schedule additional time if unable to cover everything in a single sitting Optimise communication. Language, hearing and cognition are all important factors in ACP discussions. Self preparation: It is important to know the whole case: Facts about previous treatment What other HCPs are involved What other HCPs have told the patient Possible treatment options etc. Try not to arrive at the last minute or immediately after a difficult meeting. Need time to get in to the right frame of mind

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?