professor mayur lakhani cbe frcgp frcphospicefoundation.ie/.../2014/05/2-prof-mayur-lakhani.pdf ·...
TRANSCRIPT
Professor Mayur Lakhani
CBE FRCGP FRCP
www.dyingmatters.org
• Care of the dying is an important national and international
challenge
• The area of palliative care for non cancer diagnoses is generally a
neglected area
• Major challenge of an ageing population with frailty, dementia and
co-morbidity
• Current services are not fully fit for purpose - major changes are
needed in how services are designed and delivered
• Strong primary and community care system is essential
• So is an integrated offer of services especially with social care
• Importance of societal change – taboo about discussing death and
dying
• Where is the leadership coming from to solve this?
www.dyingmatters.org
Most deaths still occur in hospital whereas people want to die
at home (70%)
92000 people with an unmet need
Health inequalities are rife -non cancer
Hospices offer gold standard but cater for a minority of deaths
20% of acute beds occupied by dying patients
3.6 unplanned admissions in last year of life, Av LOS 26 d
Complaints about hospital care often about end of life
Reticence in talking about death and dying
Number of deaths to rise by 2030 by 17%
NAO Study in 2007 (Sheffield)
Looked at all deaths in hospital in a single month (200)
40% had no medical need to be there
£4.5 million a year could be saved
Nationally this equates to £450 million
Major workstream- service and pathway redesign
GP EOLC registers are incomplete
Many dying patients are admitted to hospital inappropriately because their preferences have not been ascertained
There is evidence that by taking steps to put people on the EOLC pathway can make difference
GPs are uniquely placed to influence this
Most deaths can be anticipated
registered list
chronic disease registers
nearly one million patients seen every working day in primary care.
Majority seen over 12 months
Patients regards GPs as a critical source of support.
Notice transitions
Aim: Support GPs in conversations with patients & relatives about dying & death
31% of public would like information about EoLC from their GP
75% of GPs agree they should encourage patients to plan for EoLC.
Yet, only 5% of GPs have written a will, 42% have discussed organ donation and 23% have discussed their funeral plans
People are ‘approaching the end of life’ when they are likely to die
within the next 12 months. This includes people whose death is
imminent (expected within a few hours or days) and those with:
advanced, progressive, incurable conditions
general frailty and co-existing conditions that mean they are expected
to die within 12 months
existing conditions if they are at risk of dying from a sudden acute
crisis in their condition
Life-threatening acute conditions caused by sudden catastrophic
events.
from GMC definition –
www.gmc-uk.org/static/documents/content/End_of_life.pdf
Support for carers and families
Information for patients and carers
Spiritual care services
Step 2
Assessment,
care planning
and review
• Agreed care
plan and
regular review
of needs and
preferences
• Assessing
needs of carers
Step 3
Coordination
of care
• Strategic
coordination
• Coordination
of individual
patient care
• Rapid
response
services
Step 4
Delivery of
high quality
services in
different
settings
• High quality
care provision
in all settings
• Acute
hospitals,
community,
care homes,
hospices,
community
hospitals,
prisons, secure
hospitals and
hostels
• Ambulance
services
Step 5
Care in the
last days
of life
• Identification
of the dying
phase
• Review of
needs and
preferences for
place of death
• Support for
both patient
and carer
• Recognition of
wishes
regarding
resuscitation
and organ
donation
Step 6
Care after
death
• Recognition
that end of life
care does not
stop at the
point of death.
• Timely
verification and
certification of
death or
referral
to coroner
• Care and
support of carer
and family,
including
emotional and
practical
bereavement
support
Discussions
as the end
of life
approaches
• Open, honest
communication
• Identifying
triggers for
discussion
Step 1
The End of Life Care Pathway
Would you be surprised if this person died in the next 6-12 months?
If answer is No then:
Assess patient & family for supportive & palliative care needs. Plan care. Consider patient for general practice palliative care register
When to Initiate a Discussion about Death and Dying
At diagnosis of life limiting or progressive
condition
Clinical deterioration: pain or distress
In answer to direct question from doctor:
“Would you like to talk about your
prognosis, what you can expect and what is
likely to happen in the future?”
Prompt from family
Repeated unplanned admission
Change in all GP’s self-rated confidence in starting and having conversations pre and post pilot
May 2010 (n = 46) Sept 2010 (n = 43)
0
5
10
15
20
25
30
35
40
Not confident Not veryconfident
Confident Veryconfident
0
5
10
15
20
25
30
35
Not confident Not veryconfident
Confident Veryconfident
Nu
mb
er o
f G
Ps
Starting conversations Having conversations
It is possible to increase GPs confidence in having
end of life conversations
Conversations between GP and patients, family
members and carers result in actions which
contribute to a good death
The Dying Matters communication materials were
useful to GPs and helpful to patients
1 A 72-year-old woman with bowel cancer, liver metastases, and persistent symptoms
2 A 80-year-old man with severe chronic obstructive pulmonary disease (COPD), low body mass index and increasingly frequent emergency admissions for infective exacerbations
3. A new care home resident, 78 years old with mild/ moderate Alzheimer's disease
A 88 year fit and well widow living alone mentions (during a routine consultation for flu vaccination) that she has been to ‘yet another funeral, I wonder if I will be next’
• Mrs Jones is 35 with metastatic melanoma. Had surgery and chemo for liver and lung metastases.
• CT scans show progressive disease despite biological agents taken for the last 2 months which have now been stopped “to give them a rest”.
• Appetite is poor and very fatigued. Two children under 5. worried about how her partner is going to cope
• The oncologist has offered more treatment if Mrs Jones feels “up to it”.
• DN requests GP home visit because family is not coping
23
Commissioning is the single key mechanism for
making sure that the right services are available to
meet local need, and that they are sensitive to the
needs of those approaching the end of life
regardless of their condition.
(End of Life Care Strategy: second annual report ,
2010)
Commissioning is not contracts!
www.dyingmatters.org
Every person who is coming to the end of their life is spotted early enough and supported to make a good plan for the type of care they would like.
For that we need a transformation in public and professional attitudes to dying, clinical practices and service provision.
A strong primary care system is essential
All GPs should up-skill in key areas
Let us work together to make a good death the norm everywhere –litmus test for our societies- how we care for the dying
Let us make positive choices. People who adapt to a changing world will flourish.
Weariness about change/reform: Our number one enemy is cynicism.
There is every reason to be optimistic. What better time than now for leadership from general practice?
The best of end of life care is yet to come.
www.dyingmatters.org