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Frail Elderly, Palliative and EOLC
SCN, Reading, Thur 8th Oct 2015Dr Jeanne Fay MRCGP DPallMed
Interface Medicine, Oxford Health FT
SCN, Reading, Thur 8th Oct 2015Dr Jeanne Fay MRCGP DPallMed
Interface Medicine, Oxford Health FT
www.poppi.org.uk (ONS data)Data for: OxfordshireTable produced on 09/03/15 17:54 from www.poppi.org.uk version 9.0Population aged 65 and over, projected to 2030
2014 2015 2020 2025 2030People aged 65-69 35,300 35,900 33,200 36,600 42,300People aged 70-74 26,600 27,700 34,000 31,600 35,000People aged 75-79 21,500 21,900 25,400 31,500 29,500People aged 80-84 15,900 16,300 18,800 22,200 27,800People aged 85-89 10,100 10,500 12,300 14,700 17,800People aged 90 and over 6,300 6,500 8,200 10,700 13,900
Total pop. 65 and over 115,700 118,800 131,900 147,300 166,300Figures may not sum due to rounding. Crown copyright 2014
Oxfordshire Services
Ambulatory Care / Admission avoidance including:-•Interface Medicine via Emergency Multi-disciplinary Units (based in 2 cottage hospitals, and this month, at both acute hospitals).•Hospital at Home service•Integrated Locality teams (nursing, therapy, social work access)
Ambulatory Care / Admission avoidance including:-•Interface Medicine via Emergency Multi-disciplinary Units (based in 2 cottage hospitals, and this month, at both acute hospitals).•Hospital at Home service•Integrated Locality teams (nursing, therapy, social work access)
Admission Avoidance
Nigel Edwards, Kings Fund 201450% admissions could be avoided if an alternative service was available including •H@H, •integrated community care teams, •ambulatory medical assessment units.
Nigel Edwards, Kings Fund 201450% admissions could be avoided if an alternative service was available including •H@H, •integrated community care teams, •ambulatory medical assessment units.
Emergency Multi-disciplinary Unit
EMU Patient Pathway
EMU
• Treatment of exacerbations of long term conditions – e.g. heart failure, COPD & Asthma
• Treatment of acute medical conditions – e.g. Dehydration & AKI, UTIs, Pneumonia, Cellulitis
• Treatment of conditions causing loss of independence– e.g. Falls, Reduced mobility and functional performance
levels• Semi-Elective Blood Transfusions• Telephone advice to GPs re community options for care• Avoidance of unnecessary emergency admissions
• Treatment of exacerbations of long term conditions – e.g. heart failure, COPD & Asthma
• Treatment of acute medical conditions – e.g. Dehydration & AKI, UTIs, Pneumonia, Cellulitis
• Treatment of conditions causing loss of independence– e.g. Falls, Reduced mobility and functional performance
levels• Semi-Elective Blood Transfusions• Telephone advice to GPs re community options for care• Avoidance of unnecessary emergency admissions
The H@H Service
Part of Urgent Care Service, Launched 2011.Commissioned to provide clinical care to
patients who are sub acutely ill at home. Aims: • To prevent inappropriate admission to
hospital• To facilitate early discharge from acute or
community hospitals.
Part of Urgent Care Service, Launched 2011.Commissioned to provide clinical care to
patients who are sub acutely ill at home. Aims: • To prevent inappropriate admission to
hospital• To facilitate early discharge from acute or
community hospitals.
The H@H Patients• Referred from any health or
social care professional including paramedics.
• Most are visited once or twice each day depending on their needs (can be up to QDS)
• Work closely with specialist teams eg respiratory nurses, IV team , community diabetes nurses and EMU.... and with GP’s and DN’s
• Referred from any health or social care professional including paramedics.
• Most are visited once or twice each day depending on their needs (can be up to QDS)
• Work closely with specialist teams eg respiratory nurses, IV team , community diabetes nurses and EMU.... and with GP’s and DN’s
Referrals to Oxfordshire ILT
• The patient is ‘complex’Multiple health and/or social care needs requiring input more
than 1 health care professional
• The patient is ‘escalating’, in that if not in receipt of support today/tomorrow, they are at risk of hospital admission
And/or
• You are uncertain about what the patient needs and you need a pair of ‘eyes and ears’
• The patient is ‘complex’Multiple health and/or social care needs requiring input more
than 1 health care professional
• The patient is ‘escalating’, in that if not in receipt of support today/tomorrow, they are at risk of hospital admission
And/or
• You are uncertain about what the patient needs and you need a pair of ‘eyes and ears’
Frailty
Frailty
Frailty is a distinctive health state related to the aging process in which multiple body systems gradually lose their built in reserves to deal with challenges to health such as an infection, or even a new medication.
This is different from simply having multiple co-morbidities.
Frailty is a distinctive health state related to the aging process in which multiple body systems gradually lose their built in reserves to deal with challenges to health such as an infection, or even a new medication.
This is different from simply having multiple co-morbidities.
Frailty Syndrome – BGS Definition
1) Falls (collapse, legs gave away, lying on floor)
2) Immobility (‘off legs’; ‘stuck on the loo’)
3) Delirium (acute confusion; ‘muddledness’)
4) Incontinence (or change in continence)
5) Susceptibility to side-effects of medication (eg confusion with codeine; hypotension with anti-depressants)
BUT>50% over 80y old do NOT have frailty
DH Definition of End of Life Care
helps all those with advanced, progressive, incurable illness to live as well as possible until they die. It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support. (2008) Focus = last year of life
helps all those with advanced, progressive, incurable illness to live as well as possible until they die. It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support. (2008) Focus = last year of life
National EoLC Priorities
– Early identification of potential patients and communication of this across settings and sectors
– EoLC assessment and advance care planning for all high risk patients
– Enhanced community care services – ensuring effective investment in community settings to support disinvestment in acute services
– Early identification of potential patients and communication of this across settings and sectors
– EoLC assessment and advance care planning for all high risk patients
– Enhanced community care services – ensuring effective investment in community settings to support disinvestment in acute services
Preaching to the converted?
Preaching to the converted?
If so, then your challenge is to improve EOLC where you work, within your team …•Encourage and support colleagues to make realistic plans with patients and families.•Find out in advance about all the different services in your area that you might call on.•Consider impact on patients at the end of life of your commissioning/contracting decisions.
If so, then your challenge is to improve EOLC where you work, within your team …•Encourage and support colleagues to make realistic plans with patients and families.•Find out in advance about all the different services in your area that you might call on.•Consider impact on patients at the end of life of your commissioning/contracting decisions.
Find your 1%
• Approx 1% of the UK population die each year (over half a million),
• an average of 18-20 deaths per GP per year.• A quarter of all deaths are due to cancer, • A third from organ failure, • A third from frailty or dementia, • A twelfth of patients have a sudden death.
• Approx 1% of the UK population die each year (over half a million),
• an average of 18-20 deaths per GP per year.• A quarter of all deaths are due to cancer, • A third from organ failure, • A third from frailty or dementia, • A twelfth of patients have a sudden death.
Prognostic Indicators
The Surprise Question
‘Would you be surprised if this patient were to die within the next
year?’
‘Would you be surprised if this patient were to die within the next
year?’
Challenges of Dementia
• Dementia has uncertain time scale, diagnosis to death, more difficult to predict
• Dementia Patients’ deteriorating communication skills prevents them expressing their views later on in the disease – so have the conversations early on & encourage the setting up of LPA
• There is a burden of co-morbidity
• Dementia has uncertain time scale, diagnosis to death, more difficult to predict
• Dementia Patients’ deteriorating communication skills prevents them expressing their views later on in the disease – so have the conversations early on & encourage the setting up of LPA
• There is a burden of co-morbidity
In the UK…
People with dementia are:– more likely to die in the acute hospital– less likely to receive hospice or palliative care – less likely to have their spiritual needs considered when they die (Sampson et al 2006)
People with dementia are:– more likely to die in the acute hospital– less likely to receive hospice or palliative care – less likely to have their spiritual needs considered when they die (Sampson et al 2006)
NICE June 2010
End of Life Care for people with Dementia
A Commissioning Guide
End of Life Care for people with Dementia
A Commissioning Guide
Case 1, Mr A, 85y
PMH Ca prostate, dementia. Fall at home 18/5/15, JRH, then Comm Hosp. Found bone mets, possible liver mets. Managing a few steps with frame + 2. Admitted NH respite place Aug 15. Long term funding applied for.HPC 7w later, NH call GP, patient bed bound since admission, not eating or drinking for 4 days, ‘NH unable to provide for his needs’, & MUST be admitted to hospital same day.
PMH Ca prostate, dementia. Fall at home 18/5/15, JRH, then Comm Hosp. Found bone mets, possible liver mets. Managing a few steps with frame + 2. Admitted NH respite place Aug 15. Long term funding applied for.HPC 7w later, NH call GP, patient bed bound since admission, not eating or drinking for 4 days, ‘NH unable to provide for his needs’, & MUST be admitted to hospital same day.
Mr A, continued
GP referral to EMU ‘for investigation of reason not eating’; 2hr 2 man ambulance crew requested 3.30pm.6pm Call to NH – 1 registered nurse ‘on duty for 23 patients’, has already got another patient coming in same evening to take Mr As bed so admission cannot be delayed, even if H@H help.8.30pm Mr A arrives Witney EMU, and admitted
GP referral to EMU ‘for investigation of reason not eating’; 2hr 2 man ambulance crew requested 3.30pm.6pm Call to NH – 1 registered nurse ‘on duty for 23 patients’, has already got another patient coming in same evening to take Mr As bed so admission cannot be delayed, even if H@H help.8.30pm Mr A arrives Witney EMU, and admitted
Mr A, continued
No hand over notes from NH (no NOK detail)No purple form with patient
Malaena passed on arrivalNot hypercalcaemic on iSTATTel to daughter – v annoyed that he had been move from NH where she had been pleased with care. Clear that he was for Palliative Care.
No hand over notes from NH (no NOK detail)No purple form with patient
Malaena passed on arrivalNot hypercalcaemic on iSTATTel to daughter – v annoyed that he had been move from NH where she had been pleased with care. Clear that he was for Palliative Care.
Mr B, 85y
24/12/14 PMH Myelodysplasia, CCF, T2DM; PC SOB referred to EMU because did not want Xmas admission. Seen daily in ambulatory capacity in EMU for management of Pneumonia and AKI, with H@H support evenings.2 unit blood transfusion for anaemia (had been having them every 3 months in Oxford, last one November).
24/12/14 PMH Myelodysplasia, CCF, T2DM; PC SOB referred to EMU because did not want Xmas admission. Seen daily in ambulatory capacity in EMU for management of Pneumonia and AKI, with H@H support evenings.2 unit blood transfusion for anaemia (had been having them every 3 months in Oxford, last one November).
Mr B, continued
Feb 2015 Further bout pneumonia Feb 2015, admitted by OOHGP to Oxford, and further transfusion then. March 2015, referred to EMU for blood transfusion by Haematology Nurse specialist.Advancing disease.Patient not wanting to discuss resus status nor prognosis.
Feb 2015 Further bout pneumonia Feb 2015, admitted by OOHGP to Oxford, and further transfusion then. March 2015, referred to EMU for blood transfusion by Haematology Nurse specialist.Advancing disease.Patient not wanting to discuss resus status nor prognosis.
Mr B, cont’d
April 2015 Referral by GP to EMU. Agree to see monthly for blood transfusions, and prn if infections occur.July 2015, discussion EMU & Haematology, now on fortnightly blood transfusionsAug 2015 Hb 6, WCC 2, platelets 3 (previously 25); Creatinine 350. EMU speak with Haematology Consultant– prognosis 2-8 weeks.
April 2015 Referral by GP to EMU. Agree to see monthly for blood transfusions, and prn if infections occur.July 2015, discussion EMU & Haematology, now on fortnightly blood transfusionsAug 2015 Hb 6, WCC 2, platelets 3 (previously 25); Creatinine 350. EMU speak with Haematology Consultant– prognosis 2-8 weeks.
Mr B, cont’d
Tel EMU and GP. Challenges around Resus and prognosis discussions. Agreed joint approach, and with GP following up with home visit to wife and daughter. Goal is grandsons wedding 6w later.Agree Weekly transfusion while ambulant.
Tel EMU and GP. Challenges around Resus and prognosis discussions. Agreed joint approach, and with GP following up with home visit to wife and daughter. Goal is grandsons wedding 6w later.Agree Weekly transfusion while ambulant.
Mr B,
Final week, rectal bleeding, DN doing cross match on Wednesday concerned. Mr B in bed. Own GP away.Discussed with EMU, advised towels, stand by morphine and midazolam… Friday, GP advised not fit for transfusionSaturday grandson’s wedding.Bride & Groom visit 6pm; passed away 8pm.
Final week, rectal bleeding, DN doing cross match on Wednesday concerned. Mr B in bed. Own GP away.Discussed with EMU, advised towels, stand by morphine and midazolam… Friday, GP advised not fit for transfusionSaturday grandson’s wedding.Bride & Groom visit 6pm; passed away 8pm.
RCGP Pdf
