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Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
Recognising the Dying Patient – developing new systems for end of life care
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Recognising the Dying Patient – developing new systems for end of life care

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Sue Hanson, National Director Clinical Services, Little Company of Mary Health Care & Co-Chair NSW ACI Palliative Care Network delivered this presentation at the 2013 Managing the Deteriorating …

Sue Hanson, National Director Clinical Services, Little Company of Mary Health Care & Co-Chair NSW ACI Palliative Care Network delivered this presentation at the 2013 Managing the Deteriorating Patient conference. The management of patients in clinical deterioration has become a chief concern for Australian hospitals, with a patient’s potential for deterioration existing in every hospital ward and health service across the country. This annual event focusses on improving education for staff caring for these patients, and improving the policies and protocols in place to maintain patient safety. For more information, please visit the event website: www.healthcareconferences.com.au/deterioratingpatients

Published in: Health & Medicine, Spiritual
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  • 1. Little Company of Mary Health Care Limited Recognising the Dying Patient Developing new systems for end of life care Sue Hanson National Director Clinical Services Little Company of Mary Health Care IIR Conference Managing the Deteriorating Patient Melbourne 17 September 2013
  • 2. Calvary Hospitals and Services  Little Company of Mary Health Care Catholic Health, Aged & Community Service Provider  Calvary Care  Specialist Palliative Care Services (6)  Public Hospitals (4)  Private Acute Care Hospitals (11 + 2 Day surgeries)  Residential and Community Aged Care Services (15)  Community Support Services (28 offices)  Provide Services in  ACT, NSW, SA, VIC, NT 
  • 3. A word on language In this presentation I use these terms to mean the following  End of life  Period when a person is living with advanced, progressive life limiting illness  Differentiated by „Surprise‟ question (Lynne, 2000)  CAPC Screening Criteria for at risk patients  Palliative Care  Designated specialist services provided to people who are approaching or reaching the end of life who have complex needs  Dying  The period of time when a person‟s end of life is imminent (i.e. 0-72 hours prior to death).
  • 4. ‘Burning Deck’  143,900 people will die each year in Australia1  52+% of deaths will occur in acute care hospitals3 40% of these people will die in an ICU4  7.8 (mean) hospital admissions in last year of life5  Average 5.6 days LOS  70% visited ED  mean attendances 1.7 Cancer / 2.5 non-cancer5  75% of these deaths are clinically „expected‟2  70% of people want to die at home3 
  • 5. Care in the last year of life  People over 70 have a 30% higher chance of dying     or being severely disable within a year of a major operation In 2002 people in the last year of life consumed 801,437 bed days in NSW – 10.3% of all bed days Care in last year of life accounted for $470.6 M (2002 $) in inpatient costs – 20% of all costs for those aged >65 Forecast threefold increase in real healthcare and residential expenditure in FY07 $ over thirty year period - $85.06b ((02/03) to $246.06b (2032/33) 2.3% of privately insured use 1/3rd of all hospital benefits
  • 6. Deteriorating or dying?  Mortality in end stage chronic illness characterised by progressive deterioration  Patients who die while admitted to acute care will trigger deterioration criteria  NFR after MET 13-29% in public (Downey et al, 2008;Quach et al, 2008)  Need to have better systems to recognise end of life and dying.
  • 7. Too little too late?  Forty-nine per cent of patients were recognised as dying 24 hours or less before death  17% between 24 and 36 hours before death,  21% between 36 and 72 hours before death, and  13% greater than 72 hours before death.
  • 8. Heart Disease - CHF At least two of the indicators below: • • • • CHF NYHA stage III or IV – shortness of breath at rest or minimal exertion Patient thought to be in the last year of life by the care team - the „surprise‟ question Repeated hospital admissions with symptoms of heart failure Difficult physical or psychological symptoms despite optimal tolerated therapy.
  • 9. COPD • • • • • • • • Disease assessed to be severe e.g. (FEV1 <30%predicted – with caveats about quality of testing) Recurrent hospital admission (>3 admissions in 12 months for COPD exacerbations) Fulfils Long Term Oxygen Therapy Criteria MRC grade 4/5 – shortness of breath after 100 meters on the level or confined to house through breathlessness Signs and symptoms of right heart failure Combination of other factors e.g. anorexia, previous ITU/NIV/resistant organism, depression >6 weeks of systemic steroids for COPD in the preceding 12 months
  • 10. A redesigned systems-based approach “ an organised , deliberate approach to the identification, assessment and management of care of people approaching and reaching the end of life”
  • 11. Developing a systems approach Patient journey approaching the end of life Gateway 2 Diagnosis Chronic Gateway 1 Illness EOL Imminent Dying Death Transition Points Years 12 months 48-72 hours Death
  • 12. Gateway 2: The focus of current system Gateway 2 Gateway 1 Dx Imminent Dying EOL Death Transition Points Years 12 months 48-72 hours Death
  • 13. Gateway 1: Redesigning better care Gateway 2 Gateway 1 Dx Imminent Dying EOL Death Transition Points Years 12 months 48-72 hours Death
  • 14. A comprehensive system of care Gateway 2 Gateway 1 Dx Imminent Dying EOL Death Transition Points Years 12 months 48-72 hours Death
  • 15. Organisation wide system – key components       The use of screening and assessment tools Development of treatment algorithms or pathways Development of workforce competence frameworks Implementation of mandatory education and training units Change management Re-design and reform
  • 16. Recognising and responding to the person approaching the end of life (Gateway 1)  May not be recognised as „palliative‟ or „dying‟  Use of universal screening criteria5 in primary care, acute care and emergency departments  Establish Goals of Care   EOL Communication Understanding loss and grief  Modifying care management in line with goals of care
  • 17. Care at the transition points  Transition points occur when there is a change in clinical condition, ED presentation or admission  Revisit and review documented goals of care  Use of common assessment tools  Review care coordination and management in line with goals of care  MOLST
  • 18. Building Competence LITTLE COMPANY OF MARY HEALTH CARE National Palliative and End of Life Care Competence and Education Strategic Framework National Palliative Care Collaborative January 2012
  • 19. Competency based education ORIENTATION FOUNDATION THEORETICAL ASSESSMENT LEVEL 1 ALL STAFF & VOLUNTEERS ALL STAFF & VOLUNTEERS Volunteers Admin PCA Support Staff Introduction to mission & values of Calvary   LEVEL 2 Communication Skills Loss & Grief RN EEN EN LEVEL 3 Specialist Pal Care Clinical Staff Multidisciplinary CALVARY ON LINE TECHNICAL SKILLS  Pain & Symptom Assessment & Management Holistic Care Loss & Grief Communication       Clinical Assessment Pain Management Communication skills Advance Care Planning Care of Dying Pathway MOLST Pain & Symptom Assessment & Management Holistic Care Loss & Grief Communication         Clinical Assessment Pain Management Communication skills PCOC Assessment Syringe Drivers Advance Care Planning Care of Dying Pathway MOLST Pain & Symptom Assessment & Management Holistic Care Loss & Grief Communication           Clinical Assessment Pain Management Symptom Management Communication skills Syringe Drivers Medications PCOC Assessment Advance Care Planning Care of Dying Pathway MOLST            TRAINING PLANS POWERPOINT PRESENTATIONS COMPETENCE ASSESSMENT TOOLS
  • 20. Recognising eol – what do we hope to achieve?  High quality, appropriate care for all people approaching and reaching the end of life   Aligned with personal goals of care Closer to home  Re-empowered health, aged and social care workforce – integration of end of life care as core competence area  Care of those approaching and reaching the end of life is everybody‟s business  Improved care coordination – less reactive , crisis-based care  Strengthened primary care services  Increased use of community support services  Increased use of outreach services – take care to the patient  Diversion from „default‟ pathways – appropriate, person-centred end of life care   Reduced ED presentations Reduced acute care admissions at end of life  Collection and use of systems wide data and information  Whole of system approach provides comparable data (outcomes, service utilisation)
  • 21. LAST THOUGHTS Because I could not stop for Death, he kindly stopped for me. The Carriage held but just ourselves and Immortality Emily Dickinson

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