Part 2: Implementing the Palliative Approach Toolkit in ......© Brisbane South Palliative Care Collaborative 2014 Key Process 1: Advance Care Planning

© Brisbane South Palliative Care Collaborative 2014

Part 2: Implementing the Palliative Approach Toolkit in Residential Aged Care Unpacking the Key Processes

Focus Points:

• Advance Care Planning

• Palliative Care Case Conferences

• End of Life Care Pathways


Key Process 1: Advance Care Planning


Advance Care Planning (ACP)

Definition:

Process of planning for future health

and personal care whereby the

person’s values, beliefs and

preferences are made known so they

can guide decision-making at a future

time when the person can no longer

communicate his or her decisions1


Advance Directives

Definition:

• Written document intended to

apply to future periods of

impaired decision making

• Provides legal means for a

competent adult to instruct a

substitute decision maker and to

record preferences for future

health and personal care


Hierarchy of Decision Making

• Advance directive (as

supported by state/territory

legislation)

• Legally appointed health

attorney/guardian

• Non legally appointed

substitute decision maker

• Only comes into effect once

an individual has lost capacity


Challenges Associated with ACPs and ADs

• Lack of uniform legislation across the states and territories

• Capacity of an individual to contribute to ACP/AD

• Cross cultural considerations

• Individual’s treatment preferences may change over time

• Appropriate information to support informed decision

making

• Unclear/contradictory information on AD

• Conflicting perceptions of the meaning of an AD


Advance Care Planning in the RACF: Best Practice

• ACP is a routine component of care

• Policies and procedures in place to support ACP

• Residents and family given information about ACP before

admission

• ACP offered to residents within 28 days of admission

• ACP completed by an appropriately skilled person with the

resident and/or their family

• ACP is regularly reviewed

• System in place to transfer ACP information across health

settings1


What to Include in an ACP

• A nominated substitute decision maker (and contact details)

• Resident’s current state of health

• Resident’s values and beliefs (things that matter most in life)

• Future unacceptable health conditions

• Level of preferred future medical treatment

• Indicate specific wanted/unwanted treatments

• Goals for end of life care

• Appropriate signatures (clear, complete, dated, witnessed)

• Evidence of GP review1


Examples of ACP Documents

• Good Palliative Care Plan (see Module 2: Key processes)

• Respecting Patient Choices – Advance Care Plan (Aged Care)


Key Process 2: Palliative Care Case Conference


Prognostication: Indicators for Initiation of a Palliative Approach to Care4

Disease specific indicators

• Congestive cardiac failure

• Chronic lung disease

• Neurological disorders

• Dementia

• CVA

• Cancer

• Degenerative joint disease

Disease progression as well as increasing functional/cognitive decline +/- symptoms can indicate the need for a palliative approach to care

Disease independent indicators

• Frailty

• Functional dependence

• Behavioural changes

• Cognitive impairment

• Symptom distress

• Increased family support needs

• Recurrent infections


Palliative Care Case Conference:

Definition:

• Planned meeting using a structured process held between a resident (and/or their family) and the health care team

• Share health information and identify goals of care

• Aim for consensus in relation to treatment and care

• Document case conference outcomes and write up care plan



Organising the Meeting

Pre-planning is essential!

• Identify a facilitator/coordinator

• Who should attend?

• Invitations

• Location

• Collect information


Planning Checklist

• Track invitations

• Track documentation

• Plan case conference

goals


Family Invitation and Questionnaire

• Invitation provides:

– Date, time, location

– Staff contact

• Invitation includes responses to FAQs

– What is palliative care?

– Is my family member dying very soon?

– What is a palliative care case conference?

– Who from my family should attend?


Family Invitation and Questionnaire (continued)

• Family are able to think through their questions/concerns

• Questionnaire asks:

– What are your main issues/concerns?

– What questions would you like answered?

– For a rating of distress


Staff Communication Sheet

Staff unable to attend

palliative care case

conference (including

night and weekend

staff) are encouraged

to document any

issues, concerns or

suggestions



Conducting the Meeting

• Introductions

• What does the resident/family already know?

• Review the family questionnaire

• Discuss current health status, prognosis and treatment

options

• Review ACP/AD

• Attempt to reach consensus about current and future care

plan


Palliative Care Case Conference Summary

Document:

• Purpose

• Attendees

• Key issues

• Action plan

• GP notification


DVD from the PA Toolkit

• View the DVD: All On the Same Page

• Questions and reflections from workshop participants


Key Messages: Advance Care Planning and Palliative Care Case Conference

• ACP and PCCC improve:

- resident care outcomes

- resident and family satisfaction with care

• The ‘surprise question’ is a recognised prognostic indicator for predicting that a resident’s condition is deteriorating and end of life is approaching5

• A palliative care case conference is a planned and structured process aimed at:

- identifying the resident’s and family’s preferences for care

- formulating an agreed care plan

• Discussion with resident and family about goals of care needs to be an ongoing process and is particularly important when the resident is in the last weeks and days of life


Key Process 3: End of Life Care


End of life care is

urgent care

You only get onechance to get it right


End of Life Care

Questions to Consider:

• What are the barriers to a ‘good death’?

• What are the consequences of inadequate preparation for

death?

• What are the indicators of impending death?

• What are some of the commons symptoms experienced at

end of life?


• Integrated care pathways are structured, multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem6

Specific clinical problem = end of life care

• The RAC EoLCP is an evidence-based care plan that is used at the bedside to ensure that a dying resident receives consistent, high quality care during the last days of life7,8

What are Care Pathways?


RAC EoLCP: Benefits

• A tool designed specifically to facilitate and inform best practice end of life care in Australian RACFs

• Evidence of delivered care is automatically documented at the bedside

• Encourages consistency of care delivery across multiple settings

• Adapted to meet accreditation/funding requirements of RACFs in Australia7


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 – planning

Part B - Comfort Care Chart – documenting

Part C - Further Care Action Sheet – effectiveness

Section 4 - Multidisciplinary Communication Sheet

Section 5 - After Death Care


Commencement

= 3 or more

symptoms


Essential to Essential to

communicate

with family /

substitute

decision maker


ANZSPM Endorsed List of EoL Medications

Medication Dose StockBuscopan injection*[Hyoscine Butylbromide]

20mg/ml 5

Clonazepam drops** 2.5mg/ml 1Fentanyl Citrate injection* 100mcg/2ml 10Haloperidol injection 5mg/ml 10Hydromorphone injection 2mg/ml 5Midazolam injection* 5mg/ml 10Metoclopramide injection 10mg/2ml 10Morphine Sulphate injection 10mg/ml 5* Not on the PBS

** Non PBS unless for seizure control


Communication issues

addressed

Comfort care planning e.g.

pressure-relieving mattress

Spiritual, religious,

cultural needs addressed


Symptom

this section

Symptom

Management

Nursing staff

usually complete

this section

Routine Comfort Routine Comfort

Care

EN/AIN/PCW

usually completes

this section

Psychosocial Care

Nursing staff

usually complete

this section


action required

‘A’

assessed and no

action required

‘F/A’

further action

required

‘R/C’

routine care

‘N/A’

not applicable


‘F/A’

further action

required

‘R/C’

routine care


All ‘Further Actions’ (F/A) identified on the

‘Comfort Care Chart’ are documented and

effectiveness of care action evaluated


All relevant information that has not

been documented elsewhere on the

RAC EoLCP can be entered on the

multidisciplinary communication

sheet


Designed to be a

concise checklist


PA Toolkit Educational DVD:

How to Use the Residential Aged Care End of Life Care Pathway (RAC EoLCP)

Focus:

• Designed to train RACF staffon how to use the 5 sections in the RAC EoLCP

Key Features:

• Educational video

• Self-directed learning notes

• RAC EoLCP document

• RAC EoLCP brochure for relatives and friends


Key Messages: Using the RAC EoLCP

• Only for use during last days of life

• Goals of care reviewed with resident/relative

• Multidisciplinary team including GP and resident/relative decision to commence on RAC EoLCP

• Resident can come off the RAC EoLCP

• Point of care document

• Complete Further Actions (F/A) as they occur

• No need to duplicate information in the progress notes/chart


RAC EoLCP: Access and Enquiries

Licensing website

http://www.health.qld.gov.au/pahospital/services/raceolcp.asp

Email

[email protected]


References

1. Detering K, Hancock A, Reade M, Sylvester W (2010). The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ , 340, c1345.

2. Australian Health Ministers Advisory Council (2011). A National Framework for Advanced Care Directives: (www.ahmac.gov.au)

3. Queensland Health Advance Care Planning, http://apps.health.qld.gov.au/acp/HOME.aspx

4. Morrison R & Meier D (ed.) (2003). Geriatric palliative care. New York, NY: Oxford University Press.

5. Weissman D & Meier D (2011). Identifying Patients in Need of Palliative Assessment in the Hospital Setting. Journal of Palliative Medicine, 14(1), 17-23.

6. Campbell et al (1998). Integrated Care Pathways. BMJ, 316,133-137.

7. Reymond L, Israel F, Charles M (2011). A residential aged care end-of-life care pathway (RAC EoLCP) for Australian aged care facilities. Australian Health Review, 35, 350- 6.

8. Horey D, Street A, Sands A. (2012). Acceptability and feasibility of end-of-life pathways in Australian residential aged care facilities. Medical Journal of Australia, 197 (2), 106 – 9.