PALLIATIVE CARE

A Brief Intervention

Euan PatersonMacmillan GP Facilitator (Glasgow)

euan.paterson@ntlworld.com07792120108

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or

How to deal with ACP, ePCS and the Palliative Care DES

http://www.palliativecareggc.org.uk/

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Topics

• Anticipatory Care Planning (ACP)– Including ‘My Thinking Ahead & Making Plans’

• electronic Palliative Care Summary (ePCS)• Palliative Care DES

What I am going to cover

Some problems…

• The ‘sudden’ deterioration• What does the patient know / think / want?• What do the family know / think / want?• Lack of medication• Blue light ‘999’ at end of life• Who knows what?• The weekend catastrophe• The ‘bad’ death…• …and then 4 hours to confirm it happened!

Nothing too surprising here…

Anticipatory Care Planning (ACP)

• What is it?• Why is it (possibly) more important in palliative care?• Who is it for?

What is it?

Just what we do all the time!Every time a patient leaves the surgery or we leave their house we need to have considered – what happens next?

Why is it more important??

Not sure it is!But hugely emotive time & only one chance to get it right

Who is it for?

Who is ACP for?

• Patients with supportive / palliative care needs– Whoever YOU feel should be included!– Palliative care register– GSF register– SPICT / GSFS prognostication guidance?

Who is it for?a bit more tricky

I would argue that it is basically for who ever you feel needs it in the context of their supportive and palliative needsMaybe this is the territory of the ‘surprise question’?

Some clues fromPc registerGSFS lists

Have you come across SPICT?

Basically son of GSF PIG!

Not sure how sensitive and specific it is!

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Who is ACP for?

• Patients with supportive / palliative care needs– Whoever YOU feel should be included!– Palliative care register– GSF register– SPICT / GSFS prognostication guidance?– Chronic disease registers?– Care Home patients??– Housebound patients???

CDM registers – SPARRA???

Care homes?

Even housebound???

Anticipatory Care Planning (ACP)

• What is it?• Why is it (possibly) more important in palliative care?• Who is it for?• What are the components of ACP?

Legal Personal Medical

Potential Problems

Liverpool Care Pathway

ePCS

Welfare Power of Attorney

Advance Statement Thinking ahead & making plans

Anticipatory Care Planning

Just in Case

DNA CPRSPAR

DN Verification of Death

GSFS

Advance Care Planning

Continuing Power of Attorney

1 Statement of values2 Preferences & priorities3 Advance decision to refuse treatment4 Who else to consult

Guardianship

Anticipatory Care Planning

a busy slide!

All I really want to use it for at this point is to highlight that we have 3 major sections

Legal

Personal

Medical

And that all of this contributes to an anticipatory care plan

Legal

• Capacity– Welfare Power of Attorney– Continuing Power of Attorney– Guardianship

• Consent– To record– To transfer

• Advance decision to refuse treatment

Welfare PoA – capacity

Continuing (financial) PoA – some relevance money / care home placement

Guardianship – expensive and annual

Consent

ePCS

Advance decision to refuse treatment – awkward one

Clinical

• Consideration of potential problems- What is likely to happen to THIS patient- What might happen to THIS patient

• DNACPR• Just in Case

- Proactive prescribing

• DN Verification of Expected Death• Liverpool Care Pathway for the Dying• Bereavement

Fairly straightforward stuff that we need to think about

CriticallyWhat is probably going to happen?In end stage dementia it is quite likely that some sort of infection will be part of the very end

What could happen?Someone with spinal mets and prostate ca could get MSCC

And then the sort of processes we need to think about – and perhaps in the following orderDNACPRProactive prescribingVODLCP

And lets not forget getting ready for the inevitable bereavement

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Patient / Personal

• Preferred priorities of care– Place of care– Admission– Aggressiveness of treatment– Place of death– Who is to be involved

But now the bit that I think is possibly in need of some more work

What do our patients and their loved ones actually want?

And the more I think about anticipatory care planning the more I think that the ‘admit or not’ is the key area – place of care

How hard to treat – when to stop chemo? Antibiotics? Fluids?

Place of death

Who is important to them

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Patient / Personal

• Advance statement– Statement of values

• E.g. what makes life worth living– What patient wishes

• E.g. place of care, aggressiveness of treatment– What patient does not want

• E.g. PEG feeding, SC fluids, CPR– Who they would wish consulted

• Process– Gathering

• Sensitive consultations & discussion• My Thinking Ahead & Making Plans

– Recording

A bit more structure to what our patienst want

And then a tiny bit about the most important thing – how we do this

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The views and wishes of patient / carer

• My thinking ahead and making plans…– What is important to me just now– Planning ahead– Looking after me well– My concerns– Other important things– Things I want to know more about– Keeping track (who helped me)

• ‘An advanced statement’

Work initially carried out by Scott Murray and Kirtsy Boyd in Lothian

We’ve made some small adaptations to it for GGCThe biggest difference is the insertion of a first bullet with the focus on the ‘now’ - the lack of future narrative

Brief description of what it isAnd how it might be used

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Anticipatory Care Planning (ACP)

• What is it?• Why is it (possibly) more important in palliative care?• Who is it for?• What are the components of ACP?• ACP process

– When should this be done?– Who should do it?– How should it be done?

And then the process issues of ACP

ACP Process

• When should this be done?– At any time in life that it seems appropriate– Continuously

• Who should do it?– By anyone with an appropriate relationship!

• How should it be done?– My Thinking Ahead & Making Plans– Carefully– Write it down– Transfer it (ePCS)– Communicate

When?At any time!

Who has or had a mortgage?Did you take out any sort of policy??

Who has PoA?

LTC >>> Palliative Care

Who?We are all in this one!

How?

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The ACP Checklist

• Capacity– Power of Attorney / Possible future problems?

• Have we considered– What is likely & what might happen to this patient?– Where the patient would like to be cared for?– CPR / DNACPR?– OOH information transfer (ePCS)

• Have we considered the possible need for– Anticipatory prescribing (Just in Case)– RN Verification of Expected Death– The Liverpool Care Pathway for the Dying

• The patient / carer view– My Thinking Ahead & Making Plans…

I think that the whole ACP thing is growoing arms and legs and ive tried to get back to basics

Who is ePCS for?

• Patients with supportive / palliative care needs– Whoever YOU feel should be included!– Palliative care register– GSF register– SPICT / GSFS prognostication guidance?– Chronic disease registers?– Care Home patients??– Housebound patients???

• Perhaps need to ‘stratify’?– Supportive and Palliative Action Register (SPAR)?

Now onto ePCS

This should look familiar!!

But maybe we might need to stratify this if the numbers get big!

SPARCarmichael house

What is ePCS for?

• Information transfer– ‘In Hours’ GP > OOH– Primary Care > A&E / Acute Receiving Units– Primary Care > Scottish Ambulance Service

• Prompts for proactive care• Anticipatory Care Planning • All data stored in one place• Structure for lists / meetings / etc• Palliative care DES

What does ePCS contain?

• Information upload– Palliative Care review date– Consent to share information

• Current situation– Diagnoses– Key personnel involved– Carer details– Current treatment

• Repeat• Last 30 days Acute

– Patient & carer understanding• Diagnosis & Prognosis

What does ePCS contain?

• Future Care Plan– Patient wishes (VISION)– Preferred Place of Care– Resuscitation status– Additional drugs in house (Just in Case)– Advice for OOH GP e.g.

• Contact own GP OOH• GP willingness to sign death certificate

– Additional OOH information (KEY section) e.g.• Patient wishes• Starting Liverpool Care Pathway• Etc…

How to use ePCS

• Decide who should have one• Add data via ePCS template• Then

– Obtain consent– Add palliative care review date

• THEN– Add to Palliative Care register

• Palliative care web site– Professional / Sector / Community / ePCS

Anyone here on INPS/VISIon?

Slightly trcky in that it would appear that you need to add the patient to your register to proceed!

In EMIS if you use the e-edit tab you can sort of work back!!

This will all become easier next year!

The Palliative Care DES

• Decide who should be on it (see ACP / ePCS)• Add data via ePCS template• Then

– Obtain consent– Add palliative care review date

• THEN– Add to Palliative Care register

Now this really is familiar!

Changes for 2012-13Level 1No capStill 2wNo LCP

Level 2Will it be worth the time cost?

The Palliative Care DES

• Patient cohort – patients on palliative care register• 2011 – 12

• ACP & transfer to OOH medical service within 2 weeks• Payment based on percentage achieved• Capped c6.5/1000 patients• Payment (token!) for using LCP

• 2012 – 13• ACP & transfer to OOH medical service within 2 weeks• Payment per patient• No cap• No LCP payment• Level 2 payment for SEA

Now this really is familiar!

Changes for 2012-13Level 1No capStill 2wNo LCP

Level 2Will it be worth the time cost?