aims the prince of wales hospital service nsw health initiatives
TRANSCRIPT
![Page 1: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/1.jpg)
AIMS
• The Prince of Wales Hospital Service
• NSW Health initiatives
![Page 2: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/2.jpg)
Advance Care PlanningService
• Since 2001
• 1 CNC
• Started with Nursing Home residents & their families & GPs
• Discussion re treatments & care regarding end of life issues
• Who wants to document an ACD?
• Not 2-3 days, (usually 1-2 years)
![Page 3: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/3.jpg)
The NSW Context
• Consent– Practitioners require a valid consent– Capable Patients have the right to refuse treatment– The Guardianship Act (1987) provides a mechanism for
substitute consent for those who lack capacity to give a valid consent
• NSW Health– Using Advance Care Directives (June 04)– Guidelines for EOL care and decision-making Mar 05 – NSW Health Circular 2004/84/ Consent (Dec 04)
Circular PD2005_406 or 2004/84 is MANDATORY POLICY
![Page 4: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/4.jpg)
Documentation Standards
1. Specificity2. Currency3. Witness4. Capacity
1. It needs to apply to the clinical situation that has arisen
2. Does it reflect the current (known) wishes of the patient?
3. Has the witness verified that it was completed voluntarily
4. Assume capacity unless a valid trigger otherwise
If any of these criteria not met, it may be set aside.
![Page 5: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/5.jpg)
POWH Project1.Education
• Inservices to staff on Consent, Substitute Decision Making and how advance care directives may apply:
– RACF, Hospital & Community Health staff, – GPs at RACF mtgs, - via Divisions, interest
groups– Families via relatives mtgs in RACFs
![Page 6: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/6.jpg)
The POWH Project• Large % High level Care residents lack
capacity ~ 80%
• ?Involve Proxies/ Pers Resp– Volicer et al 2002 (JAGS 50:761-767)– Karlawish et al 1999 (Annals Int Med.
V130 N10)
• Guardianship Tribunal (previously) agreed Pers Resp can complete a Plan of Care (not an ACD!)
![Page 7: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/7.jpg)
2. An OrganisationalApproach
RESIDENTIAL CARE
– Identify Person Responsible on admission– Case conference (4-6/52 following
admission) raise Question re ACD?– Invite resident/ relative for more info– Document ACD or Plan of Care– Policy to support ACP Process
![Page 8: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/8.jpg)
2.Clinical Care
• Hospital - Follow up referrals from:– ED, Inpatient wards (POWH & SVH); Post Acute Care &
Palliative Care Services• Residential-
– Identify residents at end stage (primarily dementia):– Discussion & Documentation of ACDs or Plans of Care.
Focus on what can be done!– Resident may still require transfer to hospital for
diagnosis/symptom management if GP unavailable• Community:
– Case managers/GPs identify those wishing to explore issues further
![Page 9: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/9.jpg)
In reality….
• The majority of people with advancing dementia have never thought about what care and treatment they may want/not want & at what point………….
• as the disease progresses, they may lose the ability to discuss what is important to them or consider treatment options…
![Page 10: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/10.jpg)
MILD MODERATE SEVERE TERMINAL
MEMORYPERSONALITYSPATIALDISORIENTATION
APHASIAAPRAXIACONFUSIONAGITATIONINSOMNIA
RESISTIVENESSINCONTINENCEEATING DIFFICULTIESMOTOR IMPAIRMENT
BEDFASTMUTEDYSPHAGIAINTERCURRENT INFECTIONS
TIME
INDEPENDENCE
![Page 11: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/11.jpg)
MILD MODERATE SEVERE TERMINAL
MEMORYCLINICSConsider Subs. Dec-maker EPOA P/R E/GDiscuss?ACD
Give best opportunity for promoting capacity and ability, environment to provide input into their own care & wishesShared decision-making/ values
Plan of Care for those incapableOf consent
TIME
CAPACITY
GREY AREAFluctuating levels of confusion? Depression, delirium
Reverse what is reversible -Review when stable
![Page 12: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/12.jpg)
Decisions, Decisions…
• The decisions will fall to the “person/s responsible”
• Forewarned is forearmed
• This discussion is never easy
• Especially in an emergency!
• But questions will be asked
• Either on admission to services, aged care facilities, or, in Emergency Dept, when you least expect it….
![Page 13: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/13.jpg)
Plan of Care• Where a patient/resident is incapable of
discussing their healthcare wishes, the family, or more importantly, the “person responsible” can indicate in a Plan of Care the aims and levels of care they consider would be appropriate,
• This is done with facility staff and the via discussion with the GP.
• Other consultations/opinions may be sought.
![Page 14: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/14.jpg)
• The Plan outlines the aims of care and provides a good foundation for future treatment based on the evidence and current individual situation.
• When a patient/ resident becomes ill, the staff are aware of what the expectations are, in the context of current situation (symptoms).
• Options for treatment within the facility are noted• Facility staff involved• ED staff aware• Consent may still be required for specifics
![Page 15: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/15.jpg)
CPR / No CPR
• CPR– Use cardiac massage with mouth to mouth
breathing; may also include – Intravenous lines & drugs– electric shocks to the heart defibrillators), – tubes in throat to lungs (endotracheal tubes)
• No CPR– make no attempt to resuscitate, & you will die
![Page 16: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/16.jpg)
However!……CPR• In hospital, overall CPR successful (to
discharge from hospital) = 13% of pts treated (1)
• Pts living in long-term care (800),– success rate (admission to hospital alive) 143,
(on average <18 %, - range 8.9 - 40% ) – survival rate (discharge from hospital alive) 27 (on
average < 4% {800} - range 0-10.5%)(2)
1.Ebell et al J Gen Intern Med.1998;13:805-8162. Finucane & Harper J Am Ger Society 1999;47:1261-1264
![Page 17: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/17.jpg)
Reversible or Irreversible?Reversible• A life threatening
illness or injury that is curable, meaning that losses in my ability to function are not permanent
Irreversible• The condition is likely
to leave you an irreversible permanent disability or decrease in function
• Each of us would accept different irreversible disabilities
• Discuss with Dr and other relevant people ie, family, religious and cultural leaders
![Page 18: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/18.jpg)
Levels of Care
• Palliative/ Comfort
• Limited
• Active
• Intensive
![Page 19: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/19.jpg)
Palliative/ Comfort
• Free from pain & discomfort as much as possible
• Any treatments or investigations will be for the purpose of enhancing comfort or minimizing pain
• Analgesia• this may include surgery (ie, to relieve pain
following fracture)
![Page 20: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/20.jpg)
Limited• = Palliative, plus• May include transfer to hospital as required• Intravenous therapy (I.V or drip)• Antibiotics • Trial of appropriate drugs• blood- transfusions, tests, cross-matching• non-invasive investigations & treatments
(short of elective surgery)• No elective surgery except for pain relief
![Page 21: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/21.jpg)
Surgical/Active
• = Limited, plus
• transfer to hospital for evaluation
• gastroscopy, endoscopy, colonoscopy (all investigations) & surgery (if necessary)
• ventilation for the purposes of anaesthesia/ surgery may be included
![Page 22: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/22.jpg)
Intensive• = Surgical/Active, plus
• Transfer to hospital without hesitation
• all possible treatments in a large modern hospital
• Admit to ICU if necessary
• all options, ventilation, central venous lines, monitoring, transplants, dialysis
• do everything possible to maintain life
![Page 23: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/23.jpg)
What are the advantages and disadvantages of going to hospital for treatment as opposed to staying at home or in the aged care facility?
![Page 24: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/24.jpg)
Transfer to Acute Care• Secure environment ‘v’ elopement risk
– Restraint may be required
• Tests well tolerated if cognitively intact– Confused pt becomes anxious +/- combative
• +/- additional treatment following diagnosis– Leading to complications, therefore restraint
required: decrease in mobility, pressure areas, incontinence & hasten functional decline in vulnerable pt (3)
3.Applebaum et al J Am Ger Society 1990;38;197-200
![Page 25: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/25.jpg)
So what are the alternatives?
• Geriatrician visit
• Post Acute Care or Hospital outreach service
• Palliative Care
Depends on knowledge of local services and what is available
![Page 26: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/26.jpg)
Feeding
• Basic & Supplemental (self explanatory)
• Intravenous
• Tube
![Page 27: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/27.jpg)
Tube
• Tube feeding. There are two main types:– Nasogastric Tube a soft plastic tube passed
through the nose or mouth into the stomach
– Gastrostomy Tube a soft plastic tube passed directly into the stomach through the skin
![Page 28: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/28.jpg)
Feeding tubes• Nasogastric may be beneficial in the short
term
• But confused patients often pull them out!
• They are uncomfortable
• It could be the patient way of telling us they have had enough or are objecting
• Dilemma ….
![Page 29: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/29.jpg)
MEAN DISCOMFORT RATING (1-10)(n=100)
MEAN DISCOMFORT RATING (1-10)(n=100)
Nasogastric tube 8.8+1.9
Mechanical ventilation 8.0+5.4
Mechanical restraints 7.8+3.2
Indwelling urethral catheter 6.2+2.9
Phlebotomy 3.6+2.6
I.M. or S.C. injection 3.5+2.7
Movement from bed to chair 2.6+2.6
Morrison et al. J.Pain Sympt.Manag.15,91,1998
![Page 30: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/30.jpg)
PEG Tubes & advanced dementia
• 1996-1999 meta-analysis
• Prevent aspiration pneumonia?
• Prolong survival?
• Reduce risk of pressure sores or infections?
• Improve function?
• Provide palliation?
Finucane T et al, Tube feeding in patients with advanced Dementia: a review of the evidence JAMA Vol 282(14),1991 pp267-274
![Page 31: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/31.jpg)
What is a Palliative Approach?• Focus on care by maximising function & Quality of Life• Minimise all negative factors
– Anticipate complications (such as aspiration pneumonia)– Manage symptoms (HITH or Palliative Care)
• Maximise positive factors• Enjoyment~• Namaste (Simard)• Sensory stimulation
– Massage/ Aromatherapy– Music– Simulated presence– Taste
• You don’t need to wait until the 11th hour to adopt it!
Guidelines for a Palliative Approach in Residential Aged Care 2004. DoHA
![Page 32: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/32.jpg)
NSW Health Initiative
• Advance Care Planning in residential care
• 0.6 FTE per Area Health Service to assist residential care by fine tuning processes, improve partnerships between acute and residential, palliative care and general practice
Caplan et al Age and Ageing 2006; 35: 581–585
![Page 33: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/33.jpg)
![Page 34: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/34.jpg)
![Page 35: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/35.jpg)
So at your leisure…
• Identify -Who would be your ‘person responsible’? (Sheet 1)
• According to GT hierarchy, • Is there a need to appoint an E/Guardian?• Have you discussed issues and wishes with
them? What’s important?• What would be an intolerable functional
situation….this can be difficult to define.• Then…
• Consider documenting an ACD
![Page 36: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/36.jpg)
Sheet 2 -Consider each of the responsibilities listed in the left hand column, and write down the names of three possible spokespersons you feel are well qualified to act for you in this way
Names of Possible Spokespersons
Name 1 Name 2 Name 3
Would be willing to speak on my behalf
Would be able to act on my wishes and separate his/her own feelings from mine.
Lives close by or could travel to be at my side if needed
Knows me well and understands what’s important to me.
Could handle the responsibility.
Will talk with now about sensitive issues and will listen to my wishes.
Will be available in the future if needed
Would be able to handle conflicting opinions between family members, friends and/or medical personnel
![Page 37: AIMS The Prince of Wales Hospital Service NSW Health initiatives](https://reader030.vdocuments.mx/reader030/viewer/2022032604/56649e5f5503460f94b598f9/html5/thumbnails/37.jpg)
Tools
• My Health, My Future, My Choice:• Let Me Decide• Law Society of NSW• Planning My Future Medical Care (Catholic
Healthcare)• Colleen Cartwright (Lismore)• Hard choices for loving people (Hank Dunn)• planningwhatiwant.com.au• Respectingpatientchoices.org.au