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Care planning webinar aging2
1. Care Planning
Dr Vinay Gupta – GP Partner - Willows Health
Dr Richard Wong – Consultant Geriatrician,
Director of Older Peoples’ Care - Willows Health
2. Serious condition
Responding well
Now critical
Worsened
Responding
Critical but stable
Could be released from hospital
Remarkable progress
Returns home
Critical and at times unstable
RIP
3.
4. Current Problems with ACP / Care Planning
in the Frail Older Population
Common barriers to good practice in frailty
management and end-of-life care
Time, somebody else's job, lack of expertise
Misperceptions
Lay public
Hospitals as places of guaranteed safety
I haven’t given up yet - this is not for me
Health Professionals
Care plans will help to keep people out of hospital
Underestimate importance of time and communication (lessons from the
LCP)
It is possible to predict when an individual is near the end of life – linear
decline
5. 1st National VOICES survey of
bereaved people - 2012
• Coordination of care
Only 33% rated this highly
Feedback
Review reveals 89 patients
received substandard care
…. palliative care (patients) had tests or
investigations which, given their
prognosis, were not appropriate
Health Service Ombudsman -
2011
• Communication
• End-of-life care
6. EOL Care – A Process
Identify patients
Assess needs
Communicate & Plan
Advance Care Plans
The LCP episode
Coordinate & Provide
Across all sectors
Done
decreasingly
well
National Strategies
Education
7. Leicester, Leicestershire and Rutland ‘Deciding Right’
• EHCP (Emergency Healthcare Plan) - 1°/2 ° care
• Patient Information
• Training Healthcare workforce
8. LLR ‘Deciding Right’
• EHCP (Emergency
Healthcare Plan) - 1°/2 °
care
• EHCP PCP (2% Frail Popn)
• What matters to the
individual?
• Guidance on escalation of
care
• Patient Information
• Training Healthcare
workforce
9. • integrated model of care across London
• electronic record of patient wishes for those at the EOL
Other Initiatives
11. 203 patients (over 6 months)
113 acute hospital attendances
in the 3 months pre-intervention (in 48
patients) vs 71 acute hospital attendances
in the 3 months post-intervention (in 24
patients) - decrease of 37%
Time spent in hospital for these
patients pre-intervention vs post-
intervention: 9055 hours vs 4583 hours
(decrease of 49%)
Editor's Notes
Consequences of lack of identification
Poor care
Experiences and available services: cancer vs COPD
‘in the last year of life, patients with COPD have worse quality of life, greater limitation of activity, and more anxiety and depression than patients with lung cancer.’ (Murray et al. 2006)
Over-intervention
High incidence: prolonged/painful deaths, unwanted/futile interventions
(SUPPORT study, Knaus et al. 1995)
Physicians lacking confidence to prevent this
(Garvin and Chapman, 1995)
Unaware of patients’ changing priorities
(Steinhauser et al. 2000)
Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments
What are the uncertainties?
Prognosis
Future events
How far we should investigate illnesses (acute & chronic)?
Degrees of Intervention
The individual’s best interests
Whether or not to hospitalise for medical decompensation or adverse events?