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Ask  Document  Share  Evaluate  Advance Care Planning: It all ADSE up      Some background information…• There are over 50...
Preferred place of death in England                                        Source What we know that we didn’t know a year ...
Figure 1: The three main trajectories of decline at the end of life                                      Murray, S. A et a...
The view of Death in Society• “In Scotland, where I was born, death  was seen as imminent. In Canada, where  I trained, it...
More recent figures 2011…•   Across England people average around 2.1 admissions to hospital    in the last year of life-a...
What is ACP?Advance care planning is a voluntary process ofdiscussion and review to help an individual who hascapacity to ...
ACP: It all ADSE up• Ask: have the ACP discussion• Document: the outcomes of the  conversation• Share: the persons views w...
Birth Plan                  Advance Care                                                Plan                              ...
D= Document the outcomes of the              discussionUnder the terms of the Mental Capacity Act 2005 formalisedoutcomes ...
Preferred Priorities for CareWhat is it?       • It is an Advance Statement of preferences and         wishes as defined b...
S= Share: the persons views with       family and professional carers       With the consent of the individual the content...
E= Evaluate   Evaluate: and audit the outcomes of End of life Care     to enable services to be reviewed and revised by   ...
Peggy rallied for the wedding, watching from her armchair, surrounded by royal paraphernalia.The home organised decoration...
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Breakout 4.4 Advance Care Planning: It all ADSE up - Les Storey

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Breakout 4.4 Advance Care Planning: It all ADSE up - Les Storey
Consultant Respiratory Physician, Whittington Health & NHS Islington
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

Published in: Health & Medicine
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Transcript of "Breakout 4.4 Advance Care Planning: It all ADSE up - Les Storey"

  1. 1. Ask Document Share Evaluate Advance Care Planning: It all ADSE up Some background information…• There are over 500,000 deaths in England each year• Around 28% are of those with a cancer diagnosis• Most are from those living with a LTC/life limiting illness 1
  2. 2. Preferred place of death in England Source What we know that we didn’t know a year ago (2012) http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now.aspx The reality … Source What we know that we didn’t know a year ago (2012) http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now.aspx 2
  3. 3. Figure 1: The three main trajectories of decline at the end of life Murray, S. A et al. BMJ 2008;336:958-959Copyright ©2008 BMJ Publishing Group Ltd. Clinical Outcomes in End of Life Care • Death • Quality of death • Place of death 3
  4. 4. The view of Death in Society• “In Scotland, where I was born, death was seen as imminent. In Canada, where I trained, it was thought inevitable. In California, where I now live, it’s seen as optional.”• Ian Morrison, former president of the Institute for the Future National Audit Office Survey on End of Life Care 2008• From a survey of 200 individuals, 40% who died in hospital had no medical need to be there, and a quarter of these had been in hospital for over 1 month• 59% of admissions from Care Homes could have been avoided• The explicit recording of patient’s wishes can form the basis of care planning in MDT’s and other services, minimizing inappropriate admissions & interventionshttp://www.endoflifecareforadults.nhs.uk/publications/end-of-life-care-national-audit-office-report 4
  5. 5. More recent figures 2011…• Across England people average around 2.1 admissions to hospital in the last year of life-accounting for on average 30 bed days• 89% of those who die in hospital do so after an emergency admission• 12% who die have been admitted from a care home• Of people receiving hospice care who had an Advance care plan (ACP) 10% died in hospital compared to 26% who did not have an ACP Source What we know that we didn’t know a year ago (2012) http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now.aspx Its good to talk …The Advance Care Planning process provides a means toachieve this. Essentially ACP is about having conversationswhich facilitates and enable individuals to think about thecare that they would like to receive - we often hear theseconversations referred to as ‘difficult’ – Think of them asenabling and empowering conversations… 5
  6. 6. What is ACP?Advance care planning is a voluntary process ofdiscussion and review to help an individual who hascapacity to anticipate how their condition may affect them inthe future and, if they wish, set on record: choices abouttheir care and treatment and / or an advance decision torefuse a treatment in specific circumstances, so that thesecan be referred to by those responsible for their care ortreatment (whether professional staff or family carers) in theevent that they lose capacity to decide once their illnessprogresses.Source - Capacity, care planning and advance care planning in life limiting illness –A guide for health and social carehttp://www.endoflifecareforadults.nhs.uk/publications/pubacpguide The SANE Approach to ACP• This is a little story about four people named Somebody, Anybody, Nobody and Everybody.• There was an important job to be done and Everybody was sure that Somebody would do it.• Anybody could have done it, but Nobody did it.• Somebody got angry about that because it was Everybodys job.• Everybody thought that Anybody could do it, but Nobody realized that Everybody wouldnt do it.• It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done 6
  7. 7. ACP: It all ADSE up• Ask: have the ACP discussion• Document: the outcomes of the conversation• Share: the persons views with family and professional carers• Evaluate: and audit the outcomes of EOLC to enable services to be reviewed and revised by commissioners Barriers to ACP• About 1% of the population die each year yet often it remains difficult to identify people who are in their last year of life• Reluctance to discuss “distressing” issues• Lack of knowledge/skills/confidence• Pressures of work• Lack of good documentation 7
  8. 8. Birth Plan Advance Care Plan Preferred Priorities for Care ACP= It all ADSE up A= AskACP should discussions cover…• the person’s understanding of their illness and prognosis• the types of care and/or treatments that may be beneficial in the future and their potential availability• the person’s preferences for future care and/or treatments• the person’s concerns, fears, wishes, goals, values and beliefs, need for spiritual or religious support 8
  9. 9. D= Document the outcomes of the discussionUnder the terms of the Mental Capacity Act 2005 formalisedoutcomes of the ACP may include one or more of thefollowing• Advance statements to inform subsequent best interests decisions – e.g. PPC of which this presentation is the focus.• Advance decisions to refuse treatment (ADTR) which are legally binding if valid and applicable in the circumstances at hand• Appointment of Lasting Powers of Attorneys (LPA) for health and welfare and/or property and affairs Preferred Priorities for Care … 9
  10. 10. Preferred Priorities for CareWhat is it? • It is an Advance Statement of preferences and wishes as defined by the Mental Capacity Act(2005)Who is it for? • Anyone who wants to record their thoughts about end of life careWhen should it be completed? • As soon as appropriate, the document can be reviewed whenever an individual changes their mind The PPC is a tool which essentially serves three purposes…1. It facilitates discussion/s around end of life care wishesand preferences and from these discussions2. The PPC can enable communication for care planningand decisions across care providers3. Should the person lose capacity to make a decisionabout issues discussed, a previously completed PPCacts as an advance statement. This means that thatinformation included within the PPC can used as part ofan assessment of a person’s best interests when makingdecisions about their care. 10
  11. 11. S= Share: the persons views with family and professional carers With the consent of the individual the content of their ACP needs to be shared with those who will enact their preferences including family and health and social care professionals Paper based e.g. PPC Notification process (example to follow) Electronically e.g. Summary care Records, Adastra, Electronic palliative care co-ordination systems (EPaCCS).Preferred Priorities for Care (PPC)NOTIFICATION/AUDIT FORM Dear Colleague NHS Number: Our patient: DOB: Address: Telephone No: Diagnosis: GP: Practice Address: Has completed the above document and has stated a preference to be cared for at: HOME/ CARE HOME/ HOSPICE/ HOSPITAL (Acute/Community) (circle as applicable) Other priorities/preferences for care are: I give consent for the information contained above to be shared with the professionals identified below YES/NO (please circle as appropriate) If NO has been circled I have had the possible impact of this explained to me YES/NO I give consent for the information in this document to be used for audit purposes anonymously YES/NO (please circle as appropriate) I confirm that the information contained within the PPC is a true record of my wishes at this time. Signed…………………………………………………………………………(please print and sign) Date …………………………... Name of person initiating the document: Designation: Place of Work: Date: Contact No: Notification to: Please tick Fax Number Date General Practitioner District Nurses District Nurses Out of Hours Specialist Nurse Community Macmillan Nurses Out of Hours GP service Hospice Hospital (name) Ambulance Service Social Care Worker Other relevant professional(name) 11
  12. 12. E= Evaluate Evaluate: and audit the outcomes of End of life Care to enable services to be reviewed and revised by commissioners Local evaluations highlight the effectiveness of ACP and how this can enhance choice for individuals as end of life approaches ACP can reduce bed stay days, minimise inappropriate hospital admissions and more importantly help to meet an individuals wishes Planning for a wedding and a deathPeggy* was a centenarian who had been living in her care home for four years after suffering astroke.Over the last year of her life she suffered recurrent chest infections, resulting in two hospitaladmissions. The second admission had been quite traumatic as she had become confused anddisorientated and did not want to return.Her care home had recently introduced the PPC, Peggy was one of the first residents tocomplete a PPC with her son involved in the process.One of her chief priorities related to how she would be dressed in the final days of life. When“the time came” she did not want to be wearing some “horrid brushed cotton affair”. Fashionhad played a big part in her life and it was important she should be wearing something fitting -“a silk or satin nightgown, with a good bit of lace”!As an ardent royalist her other priority was to watch the royalwedding of Will and Kate. She would be “ready to die once theywere safely married” and wanted no further admissions to hospital.A week before the wedding Peggy suffered another infection. Thistime, in accordance with her PPC, she remained at the home.Because the staff and family had discussed and were aware of herwishes they felt reassured they were doing the right thing. 12
  13. 13. Peggy rallied for the wedding, watching from her armchair, surrounded by royal paraphernalia.The home organised decorations and a wedding breakfast. An exhausted Peggy was thrilled withthe proceedings and went to bed contentA few days later her condition deteriorated and she entered the dying phase. The staff ensuredshe was always dressed in the prettiest nightgowns. She died in a beautiful peachy satin numberwith lace edging, a large wedding photo of Will and Kate decorating the wall opposite her bed.Peggy‘s death was peaceful and pain free. She was where she wanted to be, surrounded by thepeople and things that were important to her and wearing what she wanted.The opportunity to have these discussions meant that Peggy’s wishes were defined, her careplanned and family involved. It also helped her to feel she was in control. Without thisdiscussion her wishes would not have been known.Jill Chapman, End of Life Care Pathway Facilitator- Care Homes, End of Life Care Team, Bletchley Community Hospital. 13

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