Palliative Approach Toolkit: A framework for a palliative approach to care in residential aged care facilities Professor Liz Reymond MBBS (Hons), MSc, PhD, FRACGP, FAChPM Brisbane South Palliative Care Collaborative Metro South Health
Workshop Overview Background to introduction of the Palliative Approach (PA) Toolkit for residential aged care facilities (RACFs) PA Toolkit: components, key processes and framework of care A case study illustrating use of the PA Toolkit Advance Care Planning Case Conferencing Use of an End of Life (Terminal) Care Pathway Summary
Background: Why RAC needs the PA Toolkit Consensus that end-of-life care in RACFs is less than optimal. 1,2 Australian Institute of Health and Welfare reported that 2011-2012 there were close to 180,000 people living in RACFs and that 90% of separations are due to death. 3 RACF residents are often hospitalised - 30 ED transfers for every 100 resident beds each year. 4 Estimated that 69% of RACF residents dying in hospital could have remained in the RACF to receive end-of-life care. 4 27.1% of QLD RACF permanent residents had hospital leave between July 2010 June 2011. 5 [1] Productivity Commission, Caring for Older Australians, Productivity Commission, Canberra, 2011 [2] A healthier future for all Australians Final Report June 2009. National Health and Hospitals Reform Commission, Canberra: NHHRC. [3] Australian Institute of Health and Welfare, Report on Palliative Care Services, 2012 [4] Hospitalisation of high-care residents of aged care facilities: are goals of care discussed? H Lane, R D Zordan, T J Weiland and J Philip. Internal Medicine Journal 2012 pp 144-149 [5] Figures for 1/07/10 to 30/06/11. AIHW Residential aged care in Australian 2010 11: A statistical overview
The Palliative Approach (PA) Toolkit for RACFs Purpose: Designed to assist RACFs to increase capacity to deliver comprehensive best-practice end-of-life care for their residents. Framework behind the PA Toolkit: Based on a process driven model using evidence-based tools. Components of the PA Toolkit: 3 Modules (Integrating a PA, Key processes, Clinical care), supported by a range of evidence-based practice resources (e.g. Guide to Pharmacological Management, RAC EoLCP) Brochures and forms Educational resources and DVDs National rollout: funded by DoSS and implemented by BSPCC
PA Toolkit Model of Care: Palliative Approach Trajectories Endorsed by Commonwealth Department of Social Services Consortium partners Palliative Approach Toolkit www.caresearch.com.au/patoolkit
The Palliative Approach (PA) Toolkit for RACFs Key processes: Advance care planning Case conferencing Use of an end of life (terminal) care pathway
84 year old Jack: A case study Emergency admission to Resthaven as permanent resident 12 weeks ago following sudden death of his wife who was his carer 2 children, some friction between them PMHx COAD, HT, CCF, diet controlled diabetes 2010 ICD implanted, no shocks to date 2011 2 admissions for CCF 2012 admission for CCF, MRI vascular dementia
84 year old Jack: A case study Medications: Metoprolol 50mg daily Frusemide 40mg mane Perindopril 5mg daily Warfarin Tiotrpium 18 micrograms (1 capsule) daily Atorvostatin 30mg daily Aspirin 100mg daily Paracetamol 1gm qid
84 year old Jack: A case study Saturday evening, call from facility nurse: Jack suddenly unwell Tachypnoeic, appears short of breath Restless Confused What now?
PA Toolkit Model of Care: Palliative Approach Trajectories Endorsed by Commonwealth Department of Social Services Consortium partners Palliative Approach Toolkit www.caresearch.com.au/patoolkit
Key Process: Advance Care Planning (ACP) ACP is an interactive ongoing process of communication between a competent resident, or their substitute decision maker, and the aged care team focussing on the resident s future treatment preferences Can have legally binding components (e.g. AHD and EPOA) or less formal document Allows the aged care team to know the resident s wishes so that the team can advocate for the resident
Hierarchy of Decision Making Decision maker terminology and hierarchy of decision making differs from state to state Reference: Position statement Office of the Public Advocate WA. 2013
84 year old Jack: A case study Son contacted he requested transfer to hospital Jack hospitalised and diagnosed with exacerbation of CCF and pneumonia ICU, intubated, IV inotropes and AB commenced Daughter distressed. She had not been contacted and felt current aggressive treatment against his wishes Jack stabilised, though functionally deteriorated, and returned to Resthaven What now?
PA Toolkit Model of Care: Palliative Approach Trajectories Endorsed by Commonwealth Department of Social Services Consortium partners Palliative Approach Toolkit www.caresearch.com.au/patoolkit
Key Process: Case Conferencing Identify resident and substitute decision maker concerns Share health information, estimated prognosis and what to expect as condition deteriorates Identify clear goals of care all on the same page Document case conference outcome and write up care plan
84 year old Jack: A case study What are some of the salient issues that need to be addressed in the case conference?
84 year old Jack: A case study Jack does not have decision making capacity Son and daughter joint EPOA for finance and health (through Adult Guardian) Decision made to deactivate ICD All future care to take place in Resthaven Summary of palliative case conference, including agreed treatment goals, documented and signed
84 year old Jack: A case study Six weeks later: Chest infection not improving despite 2 courses oral antibiotics Breathing moist and laboured Fluctuating consciousness Profound weakness Unable to swallow medications Minimal oral intake Daughter questions: what is happening? What now?
PA Toolkit model of care: Palliative approach trajectories Endorsed by Commonwealth Department of Social Services Consortium partners Palliative Approach Toolkit www.caresearch.com.au/patoolkit
RAC EoLCP overview Front page - Instructions Section 1 - Commencing a Resident on the RAC EoLCP [9 clinical indicators 3 or more indicate commencement] Section 2 - Medical Interventions & Advance Care Planning Section 3 - Nursing Care Staff Interventions Part A - Care Management Part B - Comfort Care Chart Part C - Further Care Action Sheet Section 4 - Multidisciplinary Communication Sheet Section 5 - After Death Care
Audit of place of resident death post implementation of RAC EoLCP 18 months across 6 RACFs = 253 deaths Not on pathway On pathway 98.3% of residents commenced on RAC EoLCP died in place Residents on RAC EoLCP significantly less likely to be transferred to hospital (1.7%) than those not on RAC EoLCP (21.5%) (χ2 = 22.9, d.f. = 1, P < 0.001) Ref: Reymond L, Israel F, Charles M. A residential aged care end of life care pathway (RAC EoLCP) for Australian aged care facilities. Australian Health Review, 2011, 35, 350 356
84 year old Jack: A case study Current condition: Semi-conscious Agitated, calling out and moaning Rattly respirations Appears to have pain with any movement Son and daughter present, both distressed What now?
Residential Aged Care Facility Medication Imprest System List for Terminal Care Medication Dose Stock Clonazepam drops* 2.5 mg/ml 1 bottle (10mls) Fentanyl Citrate injection** 100 mcg/2ml 10 ampoules Haloperidol injection 5 mg/ml 10 ampoules Hydromorphone injection 2 mg/ml 5 ampoules Hyoscine Butylbromide (Buscopan) 20 mg/ml 5 ampoules injection** Metoclopramide injection 10 mg/2ml 10 ampoules Midazolam injection** 5 mg/ml 10 ampoules Morphine Sulphate injection 10 mg/ml 5 ampoules Notes: * Non PBS unless for seizure control ** Not on the PBS April 2013
Comparison of RACF MIS List for Terminal Care with Others Medication RACF MIS WHO List South Aust. Clonazepam drops* yes no yes Fentanyl Citrate injection** yes no yes Haloperidol injection yes yes yes Hydromorphone injection yes no yes Hyoscine Butylbromide injection** yes yes yes Metoclopramide injection yes yes yes Midazolam injection** yes yes yes Morphine Sulphate injection yes yes yes Notes: * Non PBS unless for seizure control ** Not on the PBS April 2013
Thank you