aims the prince of wales hospital service nsw health initiatives
TRANSCRIPT
AIMS
• The Prince of Wales Hospital Service
• NSW Health initiatives
Advance Care PlanningService
• Since 2001
• 1 CNC
• Started with Nursing Home residents & their families & GPs
• Discussion re treatments & care regarding end of life issues
• Who wants to document an ACD?
• Not 2-3 days, (usually 1-2 years)
The NSW Context
• Consent– Practitioners require a valid consent– Capable Patients have the right to refuse treatment– The Guardianship Act (1987) provides a mechanism for
substitute consent for those who lack capacity to give a valid consent
• NSW Health– Using Advance Care Directives (June 04)– Guidelines for EOL care and decision-making Mar 05 – NSW Health Circular 2004/84/ Consent (Dec 04)
Circular PD2005_406 or 2004/84 is MANDATORY POLICY
Documentation Standards
1. Specificity2. Currency3. Witness4. Capacity
1. It needs to apply to the clinical situation that has arisen
2. Does it reflect the current (known) wishes of the patient?
3. Has the witness verified that it was completed voluntarily
4. Assume capacity unless a valid trigger otherwise
If any of these criteria not met, it may be set aside.
POWH Project1.Education
• Inservices to staff on Consent, Substitute Decision Making and how advance care directives may apply:
– RACF, Hospital & Community Health staff, – GPs at RACF mtgs, - via Divisions, interest
groups– Families via relatives mtgs in RACFs
The POWH Project• Large % High level Care residents lack
capacity ~ 80%
• ?Involve Proxies/ Pers Resp– Volicer et al 2002 (JAGS 50:761-767)– Karlawish et al 1999 (Annals Int Med.
V130 N10)
• Guardianship Tribunal (previously) agreed Pers Resp can complete a Plan of Care (not an ACD!)
2. An OrganisationalApproach
RESIDENTIAL CARE
– Identify Person Responsible on admission– Case conference (4-6/52 following
admission) raise Question re ACD?– Invite resident/ relative for more info– Document ACD or Plan of Care– Policy to support ACP Process
2.Clinical Care
• Hospital - Follow up referrals from:– ED, Inpatient wards (POWH & SVH); Post Acute Care &
Palliative Care Services• Residential-
– Identify residents at end stage (primarily dementia):– Discussion & Documentation of ACDs or Plans of Care.
Focus on what can be done!– Resident may still require transfer to hospital for
diagnosis/symptom management if GP unavailable• Community:
– Case managers/GPs identify those wishing to explore issues further
In reality….
• The majority of people with advancing dementia have never thought about what care and treatment they may want/not want & at what point………….
• as the disease progresses, they may lose the ability to discuss what is important to them or consider treatment options…
MILD MODERATE SEVERE TERMINAL
MEMORYPERSONALITYSPATIALDISORIENTATION
APHASIAAPRAXIACONFUSIONAGITATIONINSOMNIA
RESISTIVENESSINCONTINENCEEATING DIFFICULTIESMOTOR IMPAIRMENT
BEDFASTMUTEDYSPHAGIAINTERCURRENT INFECTIONS
TIME
INDEPENDENCE
MILD MODERATE SEVERE TERMINAL
MEMORYCLINICSConsider Subs. Dec-maker EPOA P/R E/GDiscuss?ACD
Give best opportunity for promoting capacity and ability, environment to provide input into their own care & wishesShared decision-making/ values
Plan of Care for those incapableOf consent
TIME
CAPACITY
GREY AREAFluctuating levels of confusion? Depression, delirium
Reverse what is reversible -Review when stable
Decisions, Decisions…
• The decisions will fall to the “person/s responsible”
• Forewarned is forearmed
• This discussion is never easy
• Especially in an emergency!
• But questions will be asked
• Either on admission to services, aged care facilities, or, in Emergency Dept, when you least expect it….
Plan of Care• Where a patient/resident is incapable of
discussing their healthcare wishes, the family, or more importantly, the “person responsible” can indicate in a Plan of Care the aims and levels of care they consider would be appropriate,
• This is done with facility staff and the via discussion with the GP.
• Other consultations/opinions may be sought.
• The Plan outlines the aims of care and provides a good foundation for future treatment based on the evidence and current individual situation.
• When a patient/ resident becomes ill, the staff are aware of what the expectations are, in the context of current situation (symptoms).
• Options for treatment within the facility are noted• Facility staff involved• ED staff aware• Consent may still be required for specifics
CPR / No CPR
• CPR– Use cardiac massage with mouth to mouth
breathing; may also include – Intravenous lines & drugs– electric shocks to the heart defibrillators), – tubes in throat to lungs (endotracheal tubes)
• No CPR– make no attempt to resuscitate, & you will die
However!……CPR• In hospital, overall CPR successful (to
discharge from hospital) = 13% of pts treated (1)
• Pts living in long-term care (800),– success rate (admission to hospital alive) 143,
(on average <18 %, - range 8.9 - 40% ) – survival rate (discharge from hospital alive) 27 (on
average < 4% {800} - range 0-10.5%)(2)
1.Ebell et al J Gen Intern Med.1998;13:805-8162. Finucane & Harper J Am Ger Society 1999;47:1261-1264
Reversible or Irreversible?Reversible• A life threatening
illness or injury that is curable, meaning that losses in my ability to function are not permanent
Irreversible• The condition is likely
to leave you an irreversible permanent disability or decrease in function
• Each of us would accept different irreversible disabilities
• Discuss with Dr and other relevant people ie, family, religious and cultural leaders
Levels of Care
• Palliative/ Comfort
• Limited
• Active
• Intensive
Palliative/ Comfort
• Free from pain & discomfort as much as possible
• Any treatments or investigations will be for the purpose of enhancing comfort or minimizing pain
• Analgesia• this may include surgery (ie, to relieve pain
following fracture)
Limited• = Palliative, plus• May include transfer to hospital as required• Intravenous therapy (I.V or drip)• Antibiotics • Trial of appropriate drugs• blood- transfusions, tests, cross-matching• non-invasive investigations & treatments
(short of elective surgery)• No elective surgery except for pain relief
Surgical/Active
• = Limited, plus
• transfer to hospital for evaluation
• gastroscopy, endoscopy, colonoscopy (all investigations) & surgery (if necessary)
• ventilation for the purposes of anaesthesia/ surgery may be included
Intensive• = Surgical/Active, plus
• Transfer to hospital without hesitation
• all possible treatments in a large modern hospital
• Admit to ICU if necessary
• all options, ventilation, central venous lines, monitoring, transplants, dialysis
• do everything possible to maintain life
What are the advantages and disadvantages of going to hospital for treatment as opposed to staying at home or in the aged care facility?
Transfer to Acute Care• Secure environment ‘v’ elopement risk
– Restraint may be required
• Tests well tolerated if cognitively intact– Confused pt becomes anxious +/- combative
• +/- additional treatment following diagnosis– Leading to complications, therefore restraint
required: decrease in mobility, pressure areas, incontinence & hasten functional decline in vulnerable pt (3)
3.Applebaum et al J Am Ger Society 1990;38;197-200
So what are the alternatives?
• Geriatrician visit
• Post Acute Care or Hospital outreach service
• Palliative Care
Depends on knowledge of local services and what is available
Feeding
• Basic & Supplemental (self explanatory)
• Intravenous
• Tube
Tube
• Tube feeding. There are two main types:– Nasogastric Tube a soft plastic tube passed
through the nose or mouth into the stomach
– Gastrostomy Tube a soft plastic tube passed directly into the stomach through the skin
Feeding tubes• Nasogastric may be beneficial in the short
term
• But confused patients often pull them out!
• They are uncomfortable
• It could be the patient way of telling us they have had enough or are objecting
• Dilemma ….
MEAN DISCOMFORT RATING (1-10)(n=100)
MEAN DISCOMFORT RATING (1-10)(n=100)
Nasogastric tube 8.8+1.9
Mechanical ventilation 8.0+5.4
Mechanical restraints 7.8+3.2
Indwelling urethral catheter 6.2+2.9
Phlebotomy 3.6+2.6
I.M. or S.C. injection 3.5+2.7
Movement from bed to chair 2.6+2.6
Morrison et al. J.Pain Sympt.Manag.15,91,1998
PEG Tubes & advanced dementia
• 1996-1999 meta-analysis
• Prevent aspiration pneumonia?
• Prolong survival?
• Reduce risk of pressure sores or infections?
• Improve function?
• Provide palliation?
Finucane T et al, Tube feeding in patients with advanced Dementia: a review of the evidence JAMA Vol 282(14),1991 pp267-274
What is a Palliative Approach?• Focus on care by maximising function & Quality of Life• Minimise all negative factors
– Anticipate complications (such as aspiration pneumonia)– Manage symptoms (HITH or Palliative Care)
• Maximise positive factors• Enjoyment~• Namaste (Simard)• Sensory stimulation
– Massage/ Aromatherapy– Music– Simulated presence– Taste
• You don’t need to wait until the 11th hour to adopt it!
Guidelines for a Palliative Approach in Residential Aged Care 2004. DoHA
NSW Health Initiative
• Advance Care Planning in residential care
• 0.6 FTE per Area Health Service to assist residential care by fine tuning processes, improve partnerships between acute and residential, palliative care and general practice
Caplan et al Age and Ageing 2006; 35: 581–585
So at your leisure…
• Identify -Who would be your ‘person responsible’? (Sheet 1)
• According to GT hierarchy, • Is there a need to appoint an E/Guardian?• Have you discussed issues and wishes with
them? What’s important?• What would be an intolerable functional
situation….this can be difficult to define.• Then…
• Consider documenting an ACD
Sheet 2 -Consider each of the responsibilities listed in the left hand column, and write down the names of three possible spokespersons you feel are well qualified to act for you in this way
Names of Possible Spokespersons
Name 1 Name 2 Name 3
Would be willing to speak on my behalf
Would be able to act on my wishes and separate his/her own feelings from mine.
Lives close by or could travel to be at my side if needed
Knows me well and understands what’s important to me.
Could handle the responsibility.
Will talk with now about sensitive issues and will listen to my wishes.
Will be available in the future if needed
Would be able to handle conflicting opinions between family members, friends and/or medical personnel
Tools
• My Health, My Future, My Choice:• Let Me Decide• Law Society of NSW• Planning My Future Medical Care (Catholic
Healthcare)• Colleen Cartwright (Lismore)• Hard choices for loving people (Hank Dunn)• planningwhatiwant.com.au• Respectingpatientchoices.org.au
