PALLIATIVE CARE. A Brief Intervention. Euan Paterson Macmillan GP Facilitator (Glasgow)

Transcription

1 PALLIATIVE CARE A Brief Intervention Euan Paterson Macmillan GP Facilitator (Glasgow) euan.paterson@ntlworld.com

2 or How to deal with ACP, epcs and the Palliative Care DES 2

3 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

4 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

5 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?

6 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 needs Maybe this is the territory of the surprise question? Some clues from Pc register GSFS lists Have you come across SPICT?

7 Basically son of GSF PIG! Not sure how sensitive and specific it is! 7

8 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???

9 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?

10 Anticipatory Care Planning Advance Care Planning Legal Personal Medical Welfare Power of Attorney Advance Statement Thinking ahead & making plans SPAR Potential Problems DNA CPR Continuing Power of Attorney Guardianship 1 Statement of values 2 Preferences & priorities 3 Advance decision to refuse treatment 4 Who else to consult GSFS epcs Just in Case Liverpool Care Pathway DN Verification of Death 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

11 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

12 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 Critically What 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 order DNACPR Proactive prescribing VOD LCP And lets not forget getting ready for the inevitable bereavement 12

13 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 13

14 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 14

15 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 GGC The 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 is And how it might be used 15

16 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

17 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? 17

18 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

19 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! SPAR Carmichael house Renfrew which is kind of next door and part of clyde

20 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 Fundamentally, this was designed to facilitate information transfer between in hours GPs and OOH GPs The rest are bonuses and so when considering shortfalls its worth comparing it with what it replaces!

21 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

22 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

23 How to use epcs - EMIS Decide who should have one Add data via epcs template (E-Edit) 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!

24 How to use epcs - VISION Decide who should have one Obtain consent Then - Add to palliative care register Then - Add palliative care review date - Add data via epcs template 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!

25 Palliative Care DES Decide who should be on it (see ACP / epcs) EMIS - Add data via epcs template - Then Obtain consent Add palliative review date - Then Add to Palliative Care Register INPS / VISION Do it ALL at once! Now this really is familiar! But note the differences between EMIS and Vision

26 Palliative Care DES ( ) Patient cohort patients on palliative care register - ACP & transfer to OOH medical service within 2 weeks - Payment based on percentage achieved - Capped c6.5/1000 patients - Payment (token!) for using LCP Current DES

27 Palliative Care DES ( ) Patient cohort patients on palliative care register Level 1 - ACP & transfer to OOH medical service within 2 weeks Diagnoses Consent Review date - Payment per patient ( 56) - Not capped - No payment for using LCP Changes for Level 1 Still 2w Very little demanded for evidence of ACP No cap No LCP Level 2 Will it be worth the time cost?

28 Palliative Care DES ( ) Level 2 - Significant Event Analysis 1 per 1000/list Malignant / non-malignant Not on PC register No epcs No DNACPR Preferred place of care / death met / not met LCP used / not used Payment administration - 23/SEA (max 1/1000/list) Will it be worth the effort?