Anticipatory Care Planning – what does it offer?

Karen J Hogg

Glasgow Royal Infirmary & Golden Jubilee National Hospital

What is anticipatory care planning?

• Process designed to support patients living with a chronic long-term condition to help plan for an expected change at some time in the future

• Voluntary progressive process of discussion

– Patient at a time where they have capacity to make healthcare decisions, family, and healthcare providers

• Patient held and led document – Prompt patients and clinicians to “think ahead” – Details patients’ current & future priorities of care

• Not legally binding – Can result in legal documentation

• DNACPR • Wills • Power of attorney

Time Onset of incurable cancer

Illness trajectory associated with cancer F

un

ctio

nal

sta

tus

Death

Good

Poor

Cancer Increased need for palliative care services

Adapted from Murray, S. A et al. BMJ 2005;330:1007-1011

Time to plan

Time

Fu

nct

ion

al

statu

s

Death

Good

Poor

Heart Failure

Unpredictable HF illness trajectory & “prognostic paralysis”

D D

D

D = clinical decompensation

Sudden cardiac death

Adapted from Murray, S. A et al. BMJ 2005;330:1007-1011

Intervention: CRT

“The physician who can foretell the course of the illness is the most highly esteemed” Hippocrates

What is needed for Medical Anticipatory Care Plan?

• Time – Explanation and discussion

• Communication skills – Some discussions can be or can become complex

• Support to follow up on difficult conversations

• Aware that these discussions can raise other issues not necessarily directly related to that patient or the issues being discussed

• Communication of MACP – Efficiently to other HCPs involved in care in 1o and 2o care – Electronic systems – Out of hours

Who should complete the Medical Anticipatory Care Plan?

• Healthcare professional – Relationship with the patient to facilitate the

appropriate conversations

– Who knows most about their condition

• May need to involve others where there are multiple co-morbidities or specific circumstances

Medical Anticipatory Care plans match preferred place of care & reduce hospital admissions

K Hogg & SMM Jenkins Medical Anticipatory Care Plans prevent hospital admissions European Heart Journal (2012) 33 (Abstract supplement) 483-484

Medical ACP No Medical ACP

Medical Anticipatory Care Plan in Practice

• 70yr old male – Chronic heart failure with severe LVSD (QRSd 118ms) – Secondary prevention ICD – Multiple co-morbidities (DM, Arthritis, COPD, CKD, AF, anaemia)

• 5 Admissions over 6 months various reasons (86 bed days)

– Pulmonary oedema & ascites – Painful cellulitic legs 2o peripheral oedema – Appropriate discharge from defibrillator – Acute on chronic renal impairment – Falls secondary to postural hypotension

Spoke with patient established priorities of care • Preferred place of care – Home

• Did not want any further hospital admission

• Rationalised • Switched high dose oral diuretics (bumetanide)

• Improved diuresis with bumetanide • Reduction in gut oedema + prokinetic improved nausea and appetite • Breathlessness improved with oxynorm which also improved pain control from arthritis • Aqueous cream + menthol & oral balance gel for dry skin and mouth

HOME FU: HF&SC clinic

HFLN service at home Day services local hospice with his wife

Medical Anticipatory Care plan

ICD Symptom Management Medical Rx

• Reprogrammed • Established his thoughts regarding previous discharges from his ICD

Outcome

• 4 months following discharge from hospital – Primarily home care with help of GP/DN and HFLN

service guided by medical ACP – Attended HF&SC clinic at GRI

• Optimised heart failure medication • Managed cardiac & non-cardiac symptoms • Ongoing discussions re timing of device deactivation • Made alterations to MACP

– Attended and benefited from day services at local hospice

– No hospital admissions – No discharges from ICD

Outcome

• 5 months following discharge from hospital

– Losing weight & developing cahexia

– Increasing symptom burden

– Spending more time in bed

– ICD was deactivated electively as planned

– Developed resistant painful ascites despite high dose oral diuretics

– Short admission to local hospice to allow for some ascitic fluid to be drained to relieve symptoms

Outcome

• 6.5 months following discharge from hospital (Hospital bed days = 0) – Died comfortably at home with family supported by

HFLN service, community palliative care and GP

– No further hospital admissions

– No further discharges from device

– Death was not a surprise and the family felt supported

– GP provided bereavement care

– Wife continued to attend local hospice for support for several months following his death