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Dr Barbara Hayes presented this at the 2014 Managing the Deteriorating Patient Conference. The conference discussed the latest strategies to recognise and respond to the acute patient in clinical deterioration. You can find out more about next year's conference at http://bit.ly/1sjQubi
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‘Goals of Patient Care’:
Proactive shared decision-making to establish medical treatment goals & treatment limitations
Dr Barbara Hayes - Palliative Care Physician Clinical Lead – Advance Care Planning
Member - Accreditation Standard 9 Committee
Managing the Deteriorating Patient Conference 2014
© B. Hayes.2014
Acknowledgement
Prof Michael Ashby and Dr Robyn Thomas from Royal Hobart Hospital & Southern Tasmania Area Health Service
Developed original Goals of Care model on which Northern Health’s approach is based.
© B. Hayes.2014
Brings together….
Person Centred Care
Advance Care Planning
Raising awareness
Capturing & implementing prior planning
Shared decision-making for potential deterioration
Medical Treatment Goals
Emergency Treatment Escalation (CPR/MET)
CPR/NFR decision-making
Community Endorsement of Medical Orders
© B. Hayes.2014
Rapid Response Teams
Initially developed to rescue deteriorating patients
- but dying patients progress through same trajectories
New role for RRTs
Diagnosing and managing EoL / dying
- up to one third of RRTs
(Jones D et al. 2013)
© B. Hayes.2014
Goals of Patient Care Summary
Doctor directed
In consultation with the patient
and/or Medical Substitute Decision-maker & family
Planning for urgent situations
or for when treating clinicians
are not around
© B. Hayes.2014
Advance Care Planning
Patient directed
In consultation with the clinicians
Planning for when the
patient can’t speak for
themselves
© B. Hayes.2014
‘ACP in 3-Steps’ © Northern Health 2009
© B. Hayes.2014
Goals of Patient Care Summary
• Routinely at the front of adult admissions to Northern Health - - All Medical Admissions
- Selected Surgical Patients (Emergency > 65yrs)
• Aim to complete within first 24-48 hours of admission
• Decisions to limit treatment must be discussed with treating Consultant (or their delegate)
© B. Hayes.2014
First of three sections:
Documents:
Substitute Medical Decision-maker Prior Advance Care Planning
© B. Hayes.2014
Second of three sections:
Documents: Medical treatment goals
© B. Hayes.2014
© B. Hayes.2014
Medical treatment goals
A quickly accessible summary of the agreed medical goals of care
Pro-active decision:
• general guidance about the ‘big-picture’ and medical treatment that is appropriate
• specific instructions about CPR and Code Blue / MET Calls etc
Identifies who has been involved in the decision
© B. Hayes.2014
Medical treatment goals
THREE treatment aims Curative or restorative
Primarily non-burdensome treatment & symptom management
Dying (Ashby MA, Stoffell B. 1997)
→ → FOUR patient medical goal categories
© B. Hayes.2014
Medical treatment goals
THREE treatment aims
→ → FOUR patient goal categories
A. Curative or restorative - no treatment limitations
B. Curative or restorative - some treatment limitations
C. Primarily non-burdensome treatment & symptom management
D. Terminal care (Ashby MA et al. 2014)
© B. Hayes.2014
Medical treatment goals based on -
…then within those constraints
…leading to
(i) A medical assessment & a medical decision about
treatment & what is possible
(ii) A shared decision-making discussion between clinician
and patient and/or substitute decision-maker
An agreed medical treatment plan including:
- Overall medical treatment goals &
- Specific emergency medical treatments / limitations
© B. Hayes.2014
Medical treatment goals
A. Curative or restorative - no treatment limitations
B. Curative or restorative - some treatment limitations
C. Primarily non-burdensome treatment & symptom management
D. Terminal care – all treatment is aimed at comfort during dying
(Ashby MA et al. 2014)
Default
© B. Hayes.2014
© B. Hayes.2014
Third of three sections:
Endorsement
• The medical orders can be endorsed after Consultant review to continue in the community or at another health service such as Residential Aged Care
should NOT come as a surprise after discharge
© B. Hayes.2014
Northern Health audit
August 2013 – Implementation
Point prevalence audit of medical admissions (Nov 2013)
• 101 files audited
82 (81%) forms completed
(Brimblecome C et al. 2014)
© B. Hayes.2014
Goals of Patient Care Summary
Systematically identifies patient’s Substitute Medical Decision-maker
Systematically captures prior ACP
Pro-actively identifies medical treatment goals and limitations to treatment escalation
Hand-over of Medical treatment orders for use in the community
© B. Hayes.2014
Goals of Patient Care Summary
Treating team know patient/family best – best placed to complete GOPC
Aim to complete at a time when discussions are more easily undertaken
Aim to avoid MET / Code Blue teams making these decisions, in a crisis, for an unknown patient
© B. Hayes.2014
References
• Ashby MA, Stoffell B. Therapeutic ratio and defined phases: proposal of an ethical framework for palliative care. BMJ 1991, 302:1322-24.
• Jones D et al. The rapid response system and end-of-life care. Current Opinion Critical Care. 2013; 19(6);616-623.
• Ashby M et al. Goals of Care: a clinical framework for limitation of medical treatment. (accepted for publication)
• Brimblecombe C et al. The Goals of Patient Care project: implementing a proactive approach to patient-centred decision making. Internal Medicine Journal. 2014; DOI: 10.1111/imj.12511
• Hayes B. Clinical model for ethical cardiopulmonary resuscitation decision-making. Internal Medicine Journal. 2013; 43:77
© B. Hayes.2014
Dr Barbara Hayes [email protected]
Managing the Deteriorating Patient Conference 2014
‘Goals of Patient Care’
© B. Hayes.2014