Talking about Living and Dying Well

Scottish Government Palliative and End of Life Care Action Plan

“Building on Progress” – particular priority:

• early identification of patients who may need palliative care

• advance/anticipatory care planning (ACP)

• palliative and end of life care in acute hospitals

• electronic palliative care summary (ePCS)

• do not attempt cardiopulmonary resuscitation (DNACPR)

Death

High

LowTime

Function

Death

High

LowTime

Function

Erratic decline eg Organ failure

6

Other2

Gradual decline e.g.Dementia, frailty

7

Death

High

LowTime

Function

5

Rapid decline eg. Cancer

GP has 20deaths perlist of 2000Patients peryear

Palliative care - trajectories

Advance Care Planning

A process of discussion between an individual and their care providers irrespective of discipline

May lead to development of

•Statement of wishes

•Welfare Power of Attorney

•Anticipatory Care Plan (ACP)

*Prepare for the worst but hope for the best *

Anticipatory Care Plan (ACP)

Dynamic document for healthcare professionals recording;

•care wishes

- eg preferred place of death, Rx not wanted

•management plan for predictable acute events

- eg anticipatory drugs

•Ceilings of treatment / levels of intervention

•DNACPR

Anticipatory Care Plan examples

Electronic Palliative Care Summary (ePCS)

- GP “owned”

- available to ambulance, A&E, NHS 24, acute admissions etc

- consent at the point of creation not viewing

Electronic Key Information Summary (eKIS)

- for anyone with long term condition

- process and communication as for ePCS

Case 1: Mrs Roberta Smyth

INTRODUCTION: 63 year old lady, attends GP for INR check following recentdischarge from hospital (COPD exacerbation and pulmonaryembolism)

PMHx:COPD diagnosed 5 years agoAlcohol excess# Neck of Femur – 2 years ago (pinned)OsteoporosisAnginaHypertension

Mrs Roberta Smyth

Social History:Lives with husband Joe in 2nd floor flatRetired textile factory workerRetried 6 years ago because of poor healthSmoker (20/day since the age of 18)2 daughters, one lives locally, other inCornwallAttends the bingo twice a week

Mrs Roberta Smyth

Medicines:Warfarin (new)Alendronate + CalcichewSimvastatinBisoprololLisinoprilThiamineVit B CoStrongPrednisiolone 10mgsSeretide

0

10

20

30

40

50

60

70

80

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Case Two: Mrs Macleod

‘Bad’ UTI

Diagnosed Diabetes

Mobility dipped

TIA

AF

Memory Decline

Vascular Dementia

Metformin

Gliclazide

Warfarin

Perindopril

Indapamide

Atenolol

Case Two: Mrs Macleod

For both cases…

What happens next?

Talking about difficult things

• What are the key Anticipatory Care Issues that can / should be raised at each stage?

• What are the key conversations that might help later?

• What are the hoped for impacts for the patient and the health service?

0

10

20

30

40

50

60

70

80

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Case Two: Mrs Macleod

‘Bad’ UTI

Diagnosed Diabetes

Mobility dipped

TIA

AF

Memory Decline

Vascular Dementia

Metformin

Gliclazide

Warfarin

Perindopril

Indapamide

Atenolol

Fall and colles

fracture

Husband dies

Infection and

admitted

Haloperidol

Alendronate

Calcichew D3 forte

Temazepam

Codeine

Key Issues Mrs Macleod

• Power of Attorney

• Balancing drug effect v risk

• Support informal structures prior to collapse

• Awareness by all of stage of illness

• Changing ceilings of therapy at different stages

Key Information on an anticipatory care plan

• Contact numbers for Relatives/ Cares• Contact numbers for community nursing team• List of main active diagnosis• Current drug list• Prompt to discuss Power of Attorney• Prompt to discuss CPR (where appropriate)• Brief outline of baseline functional status• Preferred direction of travel in case of illness

– Community Hospital– Main hospital– Remain in care Home

• Plan in case of deterioration– Including reference to more detailed disease specific care plan if present

• Consent to share information with Out of Hours service

Does it work ??

• 5,329 Anticipatory Care Plans [ACP] developed across NHS Highland

• Reduction in both emergency new admissions (29%) and emergency occupied bed days (47%) for those patients who have an ACP in place.

• Increase in both emergency new admissions (60%) and emergency OBDs (63%) for those patients who have a SPARRA score of ≥ 50% and who do not have an ACP in place.

Summary

• Anticipatory Care is a continuum from diagnosis to death

• ‘Thinking ahead’ conversations enable effective and person centred care through plans which record personal decisions.