Recognising the Dying Patient

Developing new systems for

end of life care

Little Company of Mary Health Care Limited

Sue Hanson National Director Clinical Services Little Company of Mary Health Care IIR Conference Managing the Deteriorating Patient Melbourne 17 September 2013

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

Calvary Hospitals and Services

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).

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

‘Burning Deck’

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

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.

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.

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.

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

“ an organised , deliberate approach to

the identification, assessment and management of care of people

approaching and reaching the end of life”

A redesigned systems-based

approach

Developing a systems approach

Diagnosis

Chronic

Illness

Gateway 1

EOL

Gateway 2

Imminent Dying Death

Transition Points

Years 12 months 48-72 hours Death

Patient journey approaching the end of life

Gateway 2: The focus of current system

Dx

Gateway 1

EOL

Gateway 2

Imminent Dying Death

Transition Points

Years 12 months 48-72 hours Death

Gateway 1: Redesigning better care

Dx

Gateway 1

EOL

Gateway 2

Imminent Dying Death

Transition Points

Years 12 months 48-72 hours Death

A comprehensive system of care

Dx

Gateway 1

EOL

Gateway 2

Imminent Dying Death

Transition Points

Years 12 months 48-72 hours Death

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

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

Recognising and responding to the person approaching the end of life (Gateway 1)

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

Care at the transition points

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

Competency based education

ORIENTATION FOUNDATION THEORETICAL ASSESSMENT TECHNICAL SKILLS

ALL STAFF &

VOLUNTEERS

ALL STAFF &

VOLUNTEERS

LEVEL 1 Volunteers

Admin

PCA

Support Staff

Pain & Symptom Assessment &

Management

Holistic Care

Loss & Grief

Communication

Clinical Assessment

Pain Management

Communication skills

Advance Care Planning

Care of Dying Pathway

MOLST

Introduction to

mission & values of

Calvary

Communication Skills

Loss & Grief

LEVEL 2 RN

EEN

EN

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

LEVEL 3 Specialist Pal

Care Clinical

Staff

Multi-

disciplinary

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

CALVARY ON LINE

TRAINING PLANS

POWERPOINT PRESENTATIONS

COMPETENCE ASSESSMENT TOOLS

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)

Recognising eol – what do we hope to achieve?

Because I could not stop for Death, he kindly stopped for me.

The Carriage held but just ourselves and Immortality

Emily Dickinson

LAST THOUGHTS