Anticipatory Care Planning: Time To Make It Happen - Realistic Ageing Dr Martin Wilson (Consultant Geriatrician - NHS Highland)

1. Realistic Ageing
Planning for the final chapters
Martin Wilson
Consultant Physician
Raigmore Hospital

2. The Long Walk Home

3. To help us we are going to meet..

4. First the bits I want you to take
away....

5. The biggest barrier to good
anticipatory care in older adult
is....

6. Completely unrealistic
impressions of what ageing is
actually like

7. Realistic Ageing
• Often a long phase where adults ‘could’ die
• Very dependant on intercurrent and
unpredictable events
• Can feel like a long time to be ‘dying’ or
palliative for

8. [Almost] no one thinks they will
need hands on care before they
die

9. [Almost] no one thinks they will
need hands on care before they
die
Even fewer actually plan for it...

10. Most valuable assets
1. Unpaid carers
1. Paid Carers
2. Nursing home beds
3. A human being who can explain what is going
on ..

11. Key Priorities
• Public (and clinician) education
– Dying can take longer and be less tidy than many
presume
– Very likely to need hands on personal care before
you die.....maybe for years

12. A different spin on
demographics
Age is NOT the main problem
(It is not even in the top 3!)

13. Abba and dying

15. – The majority of over-65s have 2 or more conditions
– The majority of over-75s have 3 or more conditions
Multimorbidity is common in Scotland
Epidemiology of multimorbidity. Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke,

16. Deprivation and functional impairment
Highland
Day to day activity limited a lot by long term health or disability

17. So on average
• If you are rich
– Live longer in good health
– Have a shorter proportion of life in poor health
– More likely to have single pathology
– More likely to be the sort of person that sets up
healthcare system.....
• Remember the Inverse Care Law
– Overspend tends to be in RICHEST post codes

18. Patterns to recognise and teach

19. Copyright ©2005 BMJ Publishing Group Ltd. Murray, S. A et al. BMJ 2005;330:1007-1011

20. Functional history as important as Past
Medical History
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‘Bad’ UTI
Diagnosed
Diabetes
Mobility
dipped
TIA
AF
COPD
MI

24. Current Function
• Not driving anymore
• Lift to shops
• Cooks (a bit)
• Tires more easily
• Cognitively “fine”

26. Our lady
• Probably now ‘Not in Good Health’
– Female so could be 5 to 7 years
• Long time but sounds like won’t do all that
well if major illness

27. Priorities here?
• Ensure the ‘simple things’ prompted
– Power of Attorney
– Wills
• Future protecting
– Suitable house?
– Suitable location ?
– How would you manage without the car?
• Consider ‘Time to benefit’ when considering
treatments

28. Key [reversible] determinants of
outcome
• Largely Social
– Housing
– Legal trouble
– Getting food in....
– Social isolation
• It is a medical trigger that gets folk admitted it
is a social trigger that keeps them in.

29. Key [reversible] determinants of
outcome
• The Main Medical ones
– Don’t poison your patient [Polypharmacy]
– Make sure folk know what’s wrong with them
• Adult
• Carer
• GP
• OOH (all the bits)
• Social Work

30. Why does Anticipatory Care
Planning work?
• Largely because folk have sorted things out
from themselves
• ACPs are NOT Living wills
• Try to micromanage reasons for decline (I
think futile) unless VERY close to that event.

31. Potential Medical Reasons for
decline/admission
• Stroke
• Pneumonia
• MI
• UTI Sepsis
• Delirium (any cause)
• # Neck of Femur
• GI bleed
• Bowel Obstruction
• Urinary Retention
• Complete Heart Block
• Exacerbation COPD
• Diabetic Emergency
• Drug side effect
• Etc
• Etc
• Etc

32. Systems Love Certainty
• Follow the guideline, follow the guideline,
follow the guideline
• Are they for
– IVs
– HDU
– ITU
– CPR
• Tell me now
• Tell me now
• Tell me now

33. Really specific plans DO help IF
• The deterioration is the one you expect
– Eg Pneumonia v # NOF
– COPD
– Diabetic sick day rules
• There is some sense of imminence
• Particularly good if looking at what to do the
NEXT time this occurs

34. Things
you could
die of
The thing
that
actually
gets you

35. Disclaimer
• Nonetheless it does really help for folk to have
some concept of
– What CPR is (and is not)
– What the broad levels of hospital care are
• IVs and oxygen v 3 weeks in ITU
• It really, really helps to know there general
views on stage of life and invasiveness of
treatment
– EVEN IF THOSE VIEWS UNREALISTIC

36. Big ticket social items
• Cannot get up stairs
• Cannot get food in
• Lives alone and cannot manage
– Cook alone
– Eat alone
– Dress alone
• Cannot survive without driving
• Social Isolation

37. Priorities here?
• The Adults views
–Maybe not too much longer that they will
be heard/audible
• At what point does it start to become an
unwise move to avoid a peaceful death...

38. Treatment outcomes
• Prospect of return to independence
• Prospect of death
• Prospect of existence in a reduced state

39. Unrealistic Statements :- number 1
• ‘I never want to go into a care home’
• ‘I promised him / her I would never put them
in a home’
• Never [hardly] made with any realistic
expectation of what that would mean in
practice.

40. Ideas from England

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‘Bad’ UTI
Diagnosed
Diabetes
Mobility
dipped
TIA
AF
COPD
Fall and
Lumbar
vertebral
fracture
Dementia
Diagnosed
Recurrent
UTIs
MI

44. Current Function

45. Medication
• Metformin 1 g TDS
• Gliclazide 160mg bd
• Calcichew D3 forte 1 tab twice a day
• Alendronate 70mg once a week
• Perindopril 4mg once a day
• Indapamide 2.5mg once a day Warfarin as per INR
• Seretide 250 1 puff twice a day
• Salbutamol as required
• Clopidogrel 75mg once a day
• Atorvastatin 80mg once a day
• Mirtazapine 30mg nocte
• Zopicolone 7.5 mg at night
• Oxybutinin 5mg bd
• Thyroxine 150mcg once a day
• Atrovent inhaler 4 times a day.
• Paracetamol 1g QDS
• Omeprazole 20mg once a day
• Trimethoprim 200mg once a day
prophylaxis

46. I know what I said about social
factors being the most important
BUT THAT DRUG LIST REALLY NEEDS
SORTED !

47. NHS Scotland Poly APP !!

48. 1. Identify Objectives
7. Do they know what they are
taking and why and agree ?
2. Identify Essentials
3. Identify unneccesary
meds
4. Identify Undertreatment
5. Safety Check
6. Can they take
it ? /Can we afford
it ?

49. What happens next ?

51. What makes the difference here?
• Home care (paid or unpaid (family)
– Flexibly ~???
• Respite (of whatever type)
• Care Home move BEFORE collapse
• Lots and lot and lots of wise supportive words
• A family ‘on the same page’............

52. Things that make (almost) no
difference
• Most of her pills
• CT scans, blood tests
• Admissions to ‘exclude’ things
• Anyone who focuses on just one bit

53. So all agreed ?
• Talk is good
• Focus on the whole picture
• Individualise treatment
• Treat the unit as well as the individual
• ……

66. This is a nightmare.
• Could die on any of the deteriorations
– But doesn’t
• “Learned immortality”
• “Docs said she would die 3 times so far

67. Its a nitemare unpredictable
situation
Lets call the family ‘unrealistic’

68. Families
• ‘Unrealistic Relatives’ / ‘Distant Relative
Syndrome
• Often just seeing a different reality......
– + emotion
– + really, really not wanting it to happen NOW
– + she bounce back the last 3 times this happened
– + sometime we (the health service) are a bit
rubbish

69. We really need to understand
and be able to explain frailty
And all the uncertainty that goes
with that

71. Tolstoy
'All happy families are alike; each unhappy
family is unhappy in its own way.'
Even the best Advance Planning is not as good
as a functional family who can talk about
difficult things

73. Most valuable assets
1. Unpaid carers
1. Paid Carers
2. Nursing home beds
3. A human being who can explain what is going
on ..

74. Most valuable assets
1. Unpaid carers
1. Paid Carers
2. Nursing home beds
3. A human being who can explain what is going
on ..

75. A human being who understands and
can explain ..
• What ageing is like
• PROMPT folk to think about and plan for
– Social function
– Medical Function
• Do not underestimate the impact good
prompts can have from trusted professionals

76. Final Thought

77. Public Opinion
• Public need involved at every stage.
• Real care needed that it is understood what
ACP is and is not
• Note the climate...

78. How honest are we willing to be
with the population?

79. How realistic are we about our
final years?
A minutes silent reflection......

80. Do we all expect a sudden
death ?

81. Really ?

82. Is that what you are seeing
every day?

83. Where do you think you are
going to die?

84. How much help do you think
you are going to need ?

85. How much help do you think
you are going to need ?

86. In the last hours ?

87. In the last days?

88. In the last YEARS?

89. Take Highland
Your health boards won’t be far
off...

90. Proportion of deaths
at home
1997 to 2012

91. Proportion of deaths
at home
1997 to 2012
Static

92. Proportion of deaths
in hospital
1997 to 2012

93. Proportion of deaths
in hospital
1997 to 2012
Down 16%

94. Proportion of deaths
in Care Home
1997 to 2012

95. Proportion of deaths
in Care Home
1997 to 2012
Up 30%

96. If you died in Highland in 2012

97. 13.1% of men died in a care
home

98. If you were a woman it was
26.1%

99. What Gender are the majority
of carers again ?

100. Today

101. In Scotland
Sept 2016
Figures ISD

102. 1524 adults delayed
in hospital

103. 411 Adults
Awaiting home care

104. 348 Adults
Awaiting care home

105. And figures just tell us about
the ones we know about...

106. Not the woman caring for her
man......alone

107. Not the man caring for his
woman ....alone

108. Not the isolated ones no one
sees...

109. By 2030
230,000 folk in UK will need >
20 hours care a week

110. By 2030
230,000 folk in UK will need >
20 hours care a week
And have no family or informal
support to help them

111. Before you die....

112. Before you die....
You are likely to need

113. Hands on care

114. Possibly for years

115. Someone needs to pay for it

116. Someone needs to provide it

117. Its likely to be you