Step 2 workshop

What does holistic mean to you?

What is an holistic assessment?

• Definition of ‘holistic’ An holistic assessment is one which not only

looks at the physical aspects of a person, but looks also at the psychological, social and spiritual aspects

Holistic assessment• Is a continuous process & leads to:

• More effective care and treatment of symptoms• More client-centred (client’s priority)• Improves communication between all

professionals involved with care• Improves evaluation of treatments• Reassures/includes client’s family• Improves the client’s quality of life

The whole person?

• PHYSICAL

• PSYCHOLOGICAL

• SPIRITUAL

• SOCIAL

An example is ‘total pain’

‘TOTAL PAIN’

Social

Emotional &Psychological

Personal & Spiritual

Physical

Group Work

Case study

Eloise Griffiths is a 68 year old lady with severe heart failure. She lives with her husband, Eric, who has advancing dementia. Eric was the sole carer for Eloise until 2 years ago when he was diagnosed with Alzheimer’s Disease. He remains independent, but his son and daughter have noted that he is getting confused at times.

As part of a package to increase the support for Eric, to enable him to stay at home and to care for Eloise, you have been asked to provide two visits per day, one morning to help Eloise get up and one in the evening to assist her to bed. The referral you received says the Eloise has a very limited life expectancy and that there are no other medical alternatives to managing her heart failure. She gets extremely breathless on the minimum of movement and requires continuous oxygen.

This lady is at the end of her life (if you had a register she would be ‘Amber’). Considering the above issues, how do you carry out your assessment, both generally and in relation to potential end of life issues?

Using a care planning template, consider the four following areas:• Physical• Psychological• Spiritual• Social

Assess, plan, implement, evaluate

GP review- minimum every 2 weeks and as required. Ongoing DN support

Holistic assessment

Keyworker identified

All reversible causes of deterioration explored

Communicate with patient and relatives/carers

Review or offer advance care plan- share information with patients consent

Fast track continuing

health care funding

Carer assessment and support

Equipment assessment

Anticipatory medication

prescribed and available

DNAR considered, outcome documented, information shared appropriately

Out of Hours updated-

DNAR status, PPC

Prioritised as appropriate at GSF meeting

Agree ongoing

monitoring and support to avert crisis interventions

Inform ambulance

service

GP review

Holistic assessment

All reversible causes of deterioration explored

Communicate with patient and relative/carers

Multidisciplinary Team agree patient is in the last days of life

Review or offer advance care plan-share information with patients consent

LCP initiated

OOH updated

Review package of care if necessary

Carer assessment and support

Agree ongoing monitoring and support to avert crisis interventions

Inform ambulance service

Verification of death

Certification

LCP completed

Relatives supported

DWP 1027 Booklet; What to do after a death

Significant event

analysis

Update register

Inform all relevant agencies ; social care, AHP, ambulance service, OOH, Specialist Palliative Care Team,

Funeral attendance

if appropriate

Staff supported

Follow up bereavement assessment to relative/carers

Referral of

relative/carer to bereavement counselling services as required

End of Life Care Good Practice Guide

The above chart identifies the process that should be in place to provide equitable end of life care to all people who may be in the last year of life regardless of setting.

INCREASING DECLINE Weeks

LAST DAYS OF LIFE Days

CARE AFTER DEATH

LAST YEAR OF LIFE Months

Patient identified as within last year of life approximately (see Prognostic Indicator Guidance 2011)

Patient added on to GSF register and discussed

Communicate with patient and relatives/carers

Holistic assessment

Keyworker identified

Benefits review of

patient and carer including DS1500

Access to free

prescriptions

Offer Advance Care Planning discussion consider; ADRT/PPC/MCA/DNAR/making a will-share information with patients consent

Provide information on

Blue Badge (disabled parking) scheme

Consider Macmillan

grant if required

Carer assessment and support

Agree ongoing

monitoring and support to avert crisis interventions

Out of Hours updated-

DNAR status, PPC,

Help with assessments

• What questions should you ask?

Ask….

- Nature – what is it like

- Location – where do you get it

- Severity – what is it like at its worst

- Frequency – how often do you get this

- Duration – how long does it last

- Triggers – does anything bring it on/ make it worse

- Alleviating factors – does anything relieve it

– Assessment tools useful e.g. body charts, symptom diaries.

Sweating Loss of appetite/fluid intake

Guarding Urinary & faecal incontinence

Sleep disturbance Increased confusion

Facial expression Assuming a foetal position

Agitation Increased/decreased movement

withdrawal Hard to settle

Observing behaviour

• Also what we hear, smell & sense

Be aware of overlapping symptoms

PAIN

PAIN KILLERS CONSTIPATION

MANAGE PAIN

IMPROVED MOBILITY

IMPROVED BOWELS

IMPROVED NAUSEA

MANAGE CONSTIPATION

NAUSEA

OUTCOME FOR CLIENT: IMPROVED QUALITY OF LIFE

Tools

• Do you have any examples of tools you use for assessment?

Assessment Tools

Skin Breakdown – Braden/WaterlowOral AssessmentHOPE - Spiritual assessmentPainFluidsBowels

Advance Care Planning

Aims of the session

• How does ACP fit in with a ‘good death’?

• What is ACP?

• An introduction to some of the broader aspects– Mental Capacity Act– Advance Decisions to Refuse Treatment (ADRT)– Do Not Attempt Resuscitation (DNAR)

What is a ‘good death’ in relation to a person’s choices and decision making?

What is Advance Care Planning?

• A voluntary process of discussion about future care between an individual and their care providers, irrespective of discipline. If the individual wishes, their family and friends may be included. It is recommended, with the individuals agreement, that this discussion is documented, regularly reviewed, and communicated to key persons involved in their care

NHS End of Life Programme 2008

(Gold Standards Framework)

ADVANCE CARE

PLANNING

ADVANCE STATEMENT

ADVANCE DECISIONS

Formalises what individuals and their family do wish to happen to them

Can be useful to clinicians in planning of individual’s individual care

Not legally binding and may also need Advance Decision

Formalises what individuals do not wish to happen to them

Legally binding document, eg (Advance Decision to Refuse Treatment (ADRT) and/or DNACPR

Related to capacity of decision making- Mental Capacity Act

Diagram to illustrate Advance Care Planning process

What to talk about?

Individual’s agenda:What are the individuals feelings about their illness, what

concerns do they have, what goals are they looking to reach, do they understand their illness and its prognosis, do they have particular care preferences, now and in the future?

Tools that may help trigger conversations:• Thinking about it! Prompt card• Notice board posters• Conversations for life cards• Dying Matters Resources/ Events• Reminiscence groups/ memory boxes

Documentation

The process of ACP is more important than completing any document

………….but it is important to document any ACP outcomes in the most appropriate way and communicate this with appropriate others.

Preferred Priorities for Care (PPC)

Who completes the PPC?

• Person held document, so...• Ideally the individual• Could be a relative with individual input• Could be professional/ carer with individualThen Keep it in a visible and easily

accessible placeCommunicate the presence of a PPC to others involved in their care Take any necessary actions

Recording preferences

• The explicit recording of individuals/carers wishes can form the basis of care planning in multi-disciplinary teams and other services, minimising inappropriate admissions and interventions.

In relation to your health what has been happening to you?

What are your preferences and

priorities for your future care?

Where would you like to be cared for in the future?

• Provides simple information around:

– Lasting Power of Attorney– Advance Decisions to Refuse

Treatment– Advance Care Plans

• Good way to test the water

Supporting Resources: Booklet

http://www.endoflifecareforadults.nhs.uk/publications/planningforyourfuturecare

Supporting Resources: Easy Read

• Version for use with individuals who have communication difficulties i.e. Learning disabilities, early dementia

http://www.endoflifecareforadults.nhs.uk/publications/preferred-priorities-for-care-document-easy-read-version

The PPC is NOT legally binding...

However the Mental Capacity Act 2005 dictates that when making a ‘best interest decision’ the decision maker must consider, so far as is reasonably ascertainable—

(a) the person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),

(b) the beliefs and values that would be likely to influence his decision if he had capacity, and

(c) the other factors that he would be likely to consider if he were able to do so.

Let’s go back to Eloise (i)

Choice and decision- making by, and on behalf of, people with impaired mental capacity

◦ 5 Core Principles◦ Best Interest Decisions◦ Independent Mental Capacity Advocates (IMCA’s)◦ Advance Decision to Refuse Treatment (ADRT)◦ Appointment of a Lasting Power of Attorney (LPA)

Mental Capacity Act (MCA) 2005

5 Core Principles of the MCA• A person must be assumed to have capacity unless it is established that

they lack capacity • A person is not to be treated as unable to make a decision unless all

practicable steps to help him to do so have been taken without success• A person is not to be treated as unable to make a decision merely because

of diagnosis or because he makes an unwise decision• An act done, or decision made under this Act for, or on behalf of a person

who lacks capacity must be done or made in his best interests• Before the act is done, or the decision is made , regard must be had to

whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the persons rights and freedom of action

Used in order to decide whether an individual has the capacity to make a particular decision:

• Is there an impairment of, or disturbance in the functioning of a person's mind or brain? if so

• Is the impairment or disturbance sufficient that the person lacks the capacity to make a particular decision

Two stage test for capacity

Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) – the local documentation

Local DNA(CPR) form Patient

Information

Leaflet

Hard copy

with patient

Standardised procedures

Information for you,

your relatives and carers about

Do Not Attempt Cardiopulmonary

Resuscitation(DNACPR) Decisions

April 2013 Version One

•Unfortunately, as a complex subject, there is no ‘quick overview’ but there is plenty of guidance available (see resources)•Be aware of local policy and local documentation•Communication is key•Be aware of/have systems to document individuals with completed DNACPR documentation

DNACPR

Eloise (ii)

Find out more...Advance Decision Making

List of resources from ‘Dying Matters’http://www.dyingmatters.org/page/advice-professionals

Deciding Right – a northeast initiative for making decisions in advancehttp://www.theclinicalnetwork.org/end-of-life-care---the-clinical-network/decidingright

Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)

Decision relating to cardiopulmonary resuscitation – (BMA/Resus Council/RCN)http://www.resus.org.uk/pages/dnar.pdf

DNACPR decisions: who decides and how? (NeOLCP)http://www.endoflifecare.nhs.uk/search-resources/dnacpr-web-resource.aspx