Anticipatory Care Planning: the challenges, the limitations, the - PowerPoint PPT Presentation

Anticipatory Care Planning: the challenges, the limitations, the benefits PROFESSOR D ROBIN TAYLOR CONSULTANT PHYSICIAN,, UNIVERSITY HOSPITAL WISHAW HONORARY FELLOW, UNIVERSITY OF EDINBURGH,

DEATH DENYING ADDICTION to and the CURATIVE DEATH DEFYING MEDICAL MODEL CULTURE

Anticipatory Care Plan Shared decision making Prognostic conversations Contextual honesty Cultural attitudes to human mortality and the role of health care

Anticipatory Care Plans – scope and objectives  A communication tool designed to reduced uncertainty due to discontinuity of care  A prompt designed to reduce harms by addressing overtreatment (curative intent) and undertreatment (supportive / palliative care)  A vehicle for implementing patient-centred choices and goals of care especially towards the end of life  A mechanism for reducing costs related to wasteful high-end medical interventions

Anticipatory Care Plans – an unequivocal good? - Value assumptions re. the benefits of ACPs - The myth of autonomy at the end of life - Eventual tension between what is realistic / feasible versus what is unrealistic / unattainable - Conflation of wishes of patient and those of family members - Routinisation e.g. Use of ACPs for all rest home residents (Australia) Clinicians pad for completion of ACPs (cf. immunisations, cervical smears) Robins-Browne et al. Intern Med J. 2014; 44: 957-60 .

The challenges of ACP – human reluctance to anticipate King Solomon said: “ It is better to go to a house of mourning than a house of feasting, for death is the destiny of everyone; the living should take this to heart ” So, how many of us …. have a financial plan for retirement income? - have completed an advance directive? - have life insurance / sickness insurance? - have prepared a will? - - have made funeral arrangements?

It’s just too hard! ACP perspectives: patients, families  Cultural / generational issues re. decision-making  Does not want to discuss (about 15-20%)  No idea about illness trajectory / prognosis esp. non-malignant disease  Taboo about the term “palliative care”  Think that a conversation will be anxiety-provoking (<5%)  A written plan is going to be inflexible / will need to be changed BUT ❖ Reduction in uncertainty, reassurance, peace of mind ❖ Opens the door to different goals of care Boddy et al., Aust. J Primary Health. 2013: 19: 38-45

It’s just too hard! ACP perspectives: clinical staff  Trained to treat. End of life care is someone else's job … and so is the conversation.  Reluctance to initiate conversation - “If the patient wants it they’ll ask for it”. (Only 15% of patients will ask; only 30% of doctors will take the initiative)  Time management: it takes too long: other things are more urgent  Timeliness: windows of opportunity  Review: obsolescence, the need to be up-ro-date  Medico-legal issues (Tracey, Montgomery) BUT ❖ Reduction in uncertainty, harms, and relief of moral distress ❖ Job satisfaction following a “good death” Boddy et al., Aust. J Primary Health. 2013: 19: 38-45

Organ system failure: continuous change High Occasions for a fresh ACP assessment Function Low Death 2-5 years Frequent admissions, but death often self-care becomes difficul t Time seems “unexpected”

Anticipatory Care Plans Making Choices Advanced Care Plan for patients with chronic respiratory illness

ACPs: the domains for discussion ➢ Prognosis – what does the future hold? ➢ Managing uncertainty in the acute care setting: best case scenario / worst case scenario ➢ Goals of care (incl. quality versus quantity?)

The impact of advance care planning on end of life care in elderly patients: randomised controlled trial ❖ Hospital initiated ACP ❖ 56 / 125 randomised patients died within 6 months ❖ 25/29, 86% with ACP had their end-of-life wishes respected compared with 8/27, 30% among controls (P<0.001) ❖ Family members of patients who died had significantly less stress (P<0.001), anxiety (P=0.02), and depression (P=0.002) than those of the control patients. Detering et al., BMJ 2010; 340: 1345

“It’s just too hard! Perspectives on advance care planning” “The tubes go in and the tubes go out, the tubes come in and the tubes come out, and I just wonder if anyone is ever going to make a decision about the tubes?” Boddy et al., Aust. J Primary Health. 2013: 19: 38-45

HACP: component parts ➢ Scope and triggers ➢ Reminders: capacity, discussion, previous ACP decisions ➢ No DNACPR without HACP! ➢ Goals of care ➢ Reversible problem? ➢ For full escalation? ➢ For DNACPR? ➢ Individual treatment options (disease specific list: YES / NO) ➢ Endorsement / signatures ➢ Guidelines incl. medico-legal

Discontinuity of care in crisis management ➢ What is urgent is dealt with in isolation: the context of an acute event is often neglected ➢ Limited treatment aims: to achieve recovery from the acute event ➢ Default interventions are protocol-driven and may be indiscriminate. ➢ Risk versus benefit ratio is skewed: the risks of NOT intervening motivate inappropriate decision making by out-of-hours staff

Problems with DNACPR ➢ Misunderstandings: - that success rate for CPR is high (in fact it’s only 18% overall) - DNACPR perceived to be a surrogate for withholding other treatments ➢ Discussions about DNACPR in isolation or out of context are difficult and distressing to patients, relatives and clinicians. ➢ CPR is about one potential intervention; many others are much more relevant.

Hospital ACP (HACP) – aka Treatment Escalation Limitation Plan (TELP) What interventions are appropriate / not appropriate if the patient deteriorates?

The Structured Judgement Review Method (Royal College of Physicians, London) Description of ‘problem’ Category 1 Assessment, investigation or diagnosis 2 Medication / IV fluids / electrolytes / oxygen 3 Treatment and management plan 4 Palliative or end-of-life care 5 Operation/invasive procedure 6 Clinical monitoring 7 Resuscitation following a cardiac or respiratory arrest 8 Any other type not fitting into the categories above Structured Judgment Review Method, Royal College of Physicians Hutchinson et al., BMJ Quality and Safety. 2013.

Incident Rate Ratios: all patients (n=289) HACP + DNACPR p Neither p DNACPR only HACP nor DNACPR N=155 N=113 N=21 ‘Problems’ 1.00 2.05 <0.001 1.78 <0.001 (1.62 – 2.58) (1.19 – 2.68) Non-beneficial 1.00 1.98 <0.001 1.44 0.198 interventions (1.48 – 2.64) (0.83 – 2.50) Harms 1.00 2.77 <0.001 2.61 <0.001 (1.96 – 3.92) (1.50 – 4.55) Lightbody et al. BMJ Open, 2018

Description of clinical ‘problem’ All patients HACP and DNACPR only Neither HACP as per Structured Judgment DNACPR nor DNACPR Review 1 Assessment, investigation or diagnosis 12.5 6.7 25.2 34.8 2 Medication / IV fluids / electrolytes / oxygen 19.5 12.6 33.9 58.0 3 Treatment and management plan 21.3 11.5 40.0 92.8 4 7.8 33.9 34.8 Palliative or end-of-life care 15.8 5 Operation/invasive procedure 2.8 1.1 4.4 34.8 6 Clinical monitoring 4.5 2.2 8.7 23.2 7 Resuscitation following a cardiac or respiratory arrest 2.8 0.4 4.3 58.0 8 Any other type not fitting the categories above 5.0 3.3 8.7 11.6 Rate of events per 1000 patient days

Conclusions ➢ Anticipatory Care Planning is inherently but not unequivocally good. ➢ ACPs are grounded in honest prognostic conversations and a patient-centred approach to setting goals of care. ➢ ACPs have the potential to enhance concordance between patient choices and clinical outcomes. They reduce uncertainty and harms. But they cannot deliver all things to all people. ➢ The obstacles to using ACPs are societal and institutional. Implementation will improve as the death taboo and the pre-eminence of the curative medical model are pro- actively addressed.

References 1. TREATMENT ESCALATION LIMITATION PLANNING https:// vimeo.com/204400091 Password: NHS2017 2. The impact of a treatment escalation / limitation plan on non-beneficial interventions and harms to patients approaching the end of life Lightbody et al., BMJ Open 2018; 8:e024264. doi: 10.1136/bmjopen-2018-02426