Advance Care Planning

Lynne Jackson - RPC Project Officer

GPV August 6th 2009Austin Health - Directorate of Strategy, Quality and Service Redesign

What is Respecting Patient Choices?

• An advance care planning program

• Medical and trained non medical staff facilitate advance care planning (RPC consultants)

• Uses current state legislation

• Promotes discussion about future healthcare

• Encourages patients to:• Document wishes (medical & non-

medical)• Appoint a surrogate decision maker

Background

• There is large discrepancy between wishes of dying patients and their actual end of life care

• Most people die after chronic illness, not a sudden event & ~ 50% are not competent when near death

• Family & friends have a significant chance of not knowing our views without discussion

• A doctor who is uncertain about what to do, will, with good intention, treat aggressively

• Advance care planning is aimed at improving the quality of care, especially end of life care

Respecting Patient Choices

• Respects every persons right to autonomy, dignity and fully informed consent

• This is well established ethically and legally in the practice of modern medicine

• Ethical principles:» Autonomy & Informed consent » Beneficence vs. non maleficence» Dignity

• Competent patients can refuse unwanted medical interventions, even if death is the likely outcome

• Assists individuals to reflect, choose and communicate their current and future healthcare wishes

• Respects an individuals wishes

• Educates and supports health professionals to facilitate advance care planning

Components of an Advanced Care Plan

• Appointment of surrogate decision maker - Medical Enduring Power of Attorney (MEPOA)

• Completion of a Statement of Choices– This includes patient preferences for CPR, and life-prolonging

treatment– Other more personal wishes (non medical)

• Completion of a Refusal of Treatment certificate

The person gets appropriate care during any subsequent illness and at their end of life.

Note: ACP is not about not receiving care but about receiving the right care

TRIAL: Advance Care Planning Clinician Role• Trial of a dedicated staff member ( Nurse) in Medical

wards in 2008.

• Role: – Identify suitable patients for ACP– Take referrals– Carry out Advance Care Planning where appropriate– Raise the profile of RPC on the wards– Educate relevant staff and mentoring– Encourage cultural change– Collect data

Austin Health ACP clinicians – July-Dec 2008• Pre ACP clinician – over 300 trained consultants with little

outcome- many barriers

• Now -1.2 EFT (1day/week/ ward) on 4 medical & 2 onc wards

• 542 patients seen»New MEPOA in 25% pts»New SOC in 10%, »Time per patient - approx 50 minutes

• Of the 150 patients who have now died »30% MEPOA +/- SOC »61% Discussion card »9% - Discussion, no documentation

New RPC Advance Care Planning Model In Austin Health

May 2006-Dec 2008 Med Trak data entered.

It does not account for any ACP completed and not entered into the system. Documents include a discussion card plus alternate document i.e. SOC+/-MEPOA etc. Also note the total number of pts seen.

Individual Documents Completed 06-09

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Results 2009

Quarterly Summary - 2009

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There has been a steady improvement in RPC discussion cards despite reduced staff in March and April.

A total of 307 patients have had some form of ACP completed with the clinicians between Jan -June in contrast to 423 patients for the whole of 2008.

Randomised control trial (RCT) 2007-2008

• Hypothesis: That ACP would improve the Quality of Care of elderly (>80 yr old) medical inpatients.

• 309 pts consented

↓• 154 control (C) – No ACP

↓• 156 Intervention (I) ACP – conversation

Complete a MEPOA Complete a SOC if possible

Results (16/08/2007 – 5/03/2008)

1. ACP can be done. 80% of (I) pts did some form of ACP

2. ACP means pts wishes are known and met (history audit)

3. ACP improves pts perception of Quality

(I) pts reported greater levels of satisfaction of care (survey)

4. EOL care was improved

-families of deceased pts reported increased satisfaction with EOL care (survey)

5. Family members showed less signs of anxiety and depression (validated test on family members)

Results

• First RCT (world) to show:-

– ACP can be done

– ACP actually works at end of life

• ACP benefits the patient and their family

• Study was done in acute setting

• Incompetent pts/clients ----- Next challenge

RPC- Advance Care Planning Education• Interested?

• Health Professionals- On line E-Learning (6 modules) with assessment

• One day face to face workshop– Small groups, interactive

• GP education: on line learning modules (Launched earlier this year) through RACGP.

How to be involved?

• Have a look at the RPC website at:

www.respectingpatientchoices.org.au

• Become a RPC Consultant– Education programs available throughout the year.