Presenters: Dr. Christine Jones Dr. Gaylene Hargrove Dawn - PowerPoint PPT Presentation

Presenters: Dr. Christine Jones Dr. Gaylene Hargrove Dawn Dompierre RN  

EASING THE BURDEN OF DECISION-MAKING: MAKING THE MOST OUT OF CONVERSATION Presentation Relationships with commercial interests: • Speakers Honoraria: Amgen 2

By By th the end of th this s session ssion par articipa ticipants nts wi will ll be be ab able le to:  Understand the basic concepts of MOST, Advance Care Planning (ACP) and Goals of Care  Practice MOST designations with brief clinical scenarios  Identify the unique challenges of ACP in the renal population  Access tools and resources to support conversations  Explore practice implications through a case study 3

Pt’s with chronic kidney disease are unique….. In table groups talk about what you find challenging and unique in o engaging in ACP & goals of care conversations with renal clients. 4

 CKD patients (pre-dialysis): 56 deaths  HD patients – 31 deaths  PD patients – 7 deaths The mean survival would appear to be approximately 4.5 yrs. after one starts dialysis (if you are over 65 years of age). In 2010 Dialysis Mortality Rate: 18% Total Dialysis (HD & PD) =81 Mortality rates for pt.'s with ESRD are worse than for most cancers with an overall median survival of less than 6 years, although this does vary with age. 5 End of Life Care in Nephrology 2007

What is Wh is M MOST MOST is a physician’s order that has six designations that provide direction on code status, critical care interventions, and medical interventions. • MOST is a medical order that is valid across all care settings and is honored by the BC ambulance service. • MOST replaces No CPR orders (March 19) • The MOST policy aligns with the existing: • 9.1.2 P Adult Cardiopulmonary Resuscitation (CPR) Policy. • 10.3.9 Cardiopulmonary Resuscitation for Residential Services 6

• Agr gree eement ment bet etween een pa patie ients' expr pres essed sed pr pref efer erenc ences es for r care e and do d documen umenta tati tion on in in the e med edic ical al rec ecor ord d was as 30.2 .2% Failure to Engage Hospitalized Elderly Patients and Their Families in Advance Care Planning JAMA Intern Med. 2013;173(9):778-787. doi:10.1001/jamainternmed.2013.180 7

How does s MOST T link k to ACP P & G Goals ls of Care? e? 8

Conversations about: • Written expression of wishes • Advance Directives ACP • Representation Agreements The adult engages in ACP conversations with loved ones and health care providers Conversations about: • Clarification or review of ACP • GOALS Diagnosis, prognosis, risks, and benefits of OF CARE treatment. • Medically appropriate options for health care that aligns with the adult’s goals of care. Conversations about: • Between the adult, Most Responsible Provider and other health care providers MOST about the kinds of health care to provide in certain circumstances. The Most Responsible Physician completes a MOST 9

MOST in Clinical Practice  Ihealth new platform sites: MRP places order through computerized order entry  All other sites (including community):paper form C2- only designation with CPR 10

MOST in Clinical Practice 11

Practice MOST designations • 53y.o CRF, on dialysis does not want CPR or intubation • 83 y.o frail being followed in KCC- conservative care • 19 y.o awaiting transplant • 75 y.o chronic COPD & renal failure • 84 y.o frail & moderate dementia living in residential care • 79 y.o CHF, does not want CPR or to go to ICU 12

Advance ance Car are e Pl Plan anning: ning: is a capable adult's planning for how consent to health alth ca care will be given/refused after he/she loses capability Is a way for you to think, talk and plan together with your family, friends and healthcare providers about values, hopes and fears for your current and future health care in advance of a time you are incapable of deciding for yourself 13

14 ADVANCE CARE PLANNING  Conversations (Serious Illness Conversations)  Expression of wishes/Living Will(U.S term)  Substitute Decision Maker (ex. Representative, TSDM)  Advance Directive  Note: POA: Finances in BC

 Some adults are very clear about a treatment they want or do not want  Decreases panic and uncertainty in a crisis  Decreases moral distress for client, families and HCP  Can provide a peaceful end of life experience for the patient, family, and staff.  Individuals wishes are honored and have fewer life-sustaining procedures and lower rates of intensive care unit admissions  Protects the autonomy of client decisions  Promotes client/family-centered care

 8 out of every 10 Canadians have never heard of Advance Care Planning  only 9% had ever spoken to a healthcare provider about their wishes for care  over 80% of Canadians do not have a written plan  only 46% have designated a substitute decision maker – someone to speak on their behalf if they could not communicate March 2012 Ipsos-Reid national poll 16

Barriers to ACP Conversations Physician related Patient related • • Lack of training and comfort with EOL Inadequate knowledge about ACP decision making • Perception that ACP is difficult to • Belief that ACP discussion are not facilitate and/or execute needed • Perception that it will not be followed • Belied that pt.'s and families do not • Belief that it is the physicians role to want these discussion initiate • Time constraints • Reluctance to broach the issue of • Postponing until pt. too ill to death and EOL planning participate fully in the discussions fully • Unnecessary because family will • Concern it may destroy hope know what to do ACP in Patients with end-stage-renal disease, S. Davison (2009)

My Voice: Page 8 1 P.30 2 P.28 3 18

 Atul Gawande http://www.youtube.com/watch ?v=45b2QZxDd_o &feature=list_related&playnext= 1&list=SP602EF6A965291D5E

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It is important to go into an ACP conversation without preconceived assumptions or predictions about what people will or should feel or believe. Don’t assume how other people are feeling. Let them Tell you. 21

22 ● Ide deally: y: Healthy Capable Adults to create awareness, normalize Advance Care Planning ● More e Imper mperativ ative e Wi With: Capable Adults with Chronic Diseases before they become acutely ill ● Absolut olutel ely: y: Capable Adults with Life Expectancy Less Than 12 months

 What do I value in terms of my emotional, mental and physical health?  What would make prolonging life unacceptable for me?  When I think about death I worry about certain things happening  What brings me comfort?  Do I have any spiritual or religious beliefs that would affect my care at the end of life? Action: My wishes for care at the end of life work sheet 23

 Person who makes medical decisions on your behalf  They will give or refuse consent to treatment in the event you are incapable Action: Take a few minutes to think about 2 people that would act as your Substitute decision maker 24

My Voice:  spouse (incld. common-law & same sex) Page 9  adult child  parent  brother or sister  Grandp dparen ent t  Grandc dchi hild ld  another relative by birth or adoption  clos ose e frie iend d  pe person im immed edia iatel ely y rel elated ed by marria iage ge  another person appointed by Office of the Public Guardian and Trustee 25 25

P.34-43 P.44-49 P.50-51 26

REPRESENTATION AGREEMENT 27 An adult while capable appoints someone to make health and personal care decisions on their behalf in the event they are unable to speak for themselves Section ion 7 agreement: t: Secti tion on 9 A Agreemen eement: t:  Must t be fully ly capable able  intended for persons with less than full capability  power to refuse life- sustaining treatment o (e.g., clients with developmental disabilities).  may include decisions  for ro routi utine ne health and about admission to financial decisions residential care  does not allow the Rep to  does NOT allow Rep to refuse life support or life make financial or legal prolonging medical decisions interventions

 A capable adult can create an Advance Directive  Advance Directive is a document that gives/ refuses consent to specific treatments in advance  Leg egally y bin indi ding doc g documen ument t for r hea ealth h care e pr provi vide ders, s, document is used as the source of consent without an intermediary  Legal and medical advice is recommended before completing 2 8 28

A c A copy: y:  On your fridge (Paramedics may only check for it there)  Copy to family doctor  Copy for your Representative, friend(s) or family member(s)  Copy with other health care providers involved in your care  Copy to your lawyer/notary (if appropriate) 29