Dr David PlumeMacmillan GP Facilitator

Central Norfolk

• Formerly known as Preferred Place of Care• Lancashire and South Cumbria Cancer Network.• Originally patient-held form for people living in the

community with a cancer diagnosis• Focus on where people wanted to be cared for at the

end of their lives. • Now Preferred Priorities for Care. • Place only one possible priority.• Priorities, preferences and wishes also important. • ID’d within the NHS End of Life Care programme as an

example of an advance care plan.

• Advance Care Planning• “process of discussion between an individual and

their care providers.” (The PPC Document: Guidelines for Health and/or Social Care Staff)

• Add “Continuing”• What are this patients feelings on their disease,

what concerns do they have, what goals are they looking to reach, do they understand their illness and its prognosis, do they have particular care preferences, now and in the future?

• Know your patient!

• Not legally binding • but• MCA (2005)• Any person making a decision regarding

care/treatment of a P lacking capacity has to take into account any statement of wishes and preferences.

• Therefore has legal status• Patient needs to take into any health encounter.

• 2 new proxies– Lasting Powers of Attorney (P appoints, decides on

P’s behalf)– Court appointed Deputies (appointed and makes

decisions on P’s behalf)• 1 advocate– Independent Mental Capacity Advocates (advocate,

don’t make decisions)• Refusal of treatment

www.ncpc.org.uk

• Absolutely anyone!• Life limiting illness• Doesn’t have to be cancer.• Allows patients to have input into planning

their own future.

• Planning and being in control is important for some patients.

• Limitation should not be placed on them due to diagnosis, age, gender, sexual orientation, race or beliefs.

• Routine review– Possibly patient initiated

• Anticipated decline– Patient or professional initiated

• There is no specific time appropriate for everyone.

• Sooner the better-even at diagnosis!– More gentle conversation– More likely patient will be able to fill in– More time for patient to think and discuss with

family/friends– Easier to plan logistics with family, friends, GP, social

care professionals, specialists etc.– Have to be prepared to alter and adjust plans over

time.

• Patient held document• Ideally patient• Could be a relative with patients input• Could be professional with patient• Potentially an individual with LPA could fill in

for a patient.

• Real potential to improve patients experience• Provides idea of patients wishes• Personally responsive health system• May provoke discussion and conversations• Allows better planning of services• Allows patients freedom to change their mind,

but still have their views listened to.

• May spark difficult conversations within families• Patients written views may end up being a product of coercion by

others-”you don’t want that, think of mums health!”• Potential for patients stated wishes to “trap” other family members

into caring role-”what ever happens I want to stay at home” “my wife will look after me” “I certainly don’t want any carers”

• Patients may feel aggrieved if their preferred priorities of care are not met, -raised expectations.

• Implementation and delivery costs include leaflets, paperwork, and the time of a highly trained professional, who could be utilized elsewhere.

• May require sizable service re distribution towards primary or tertiary care.

• May require money currently going to secondary/tertiary care to be redistributed to social care.

• Meetings for last year– ASSD– Specialist Palliative Medicine– GSF Facilitators– GSF in Care Home Facilitator– GP Facilitator– Community Specialist Palliative Care Teams– District Nurses– LCP Lead Nurse

• Workshop for professionals involved in implementing the PPoC Pilot.– DN’s– SW’s– LCP Lead Nurse– GP Facilitator– CSPCN– GSF in Care Homes Facilitator– GSF Facilitators– Care Home Managers

• Review of documentation, experience of completing the document, look at potential pitfalls of the document, and support.

• Implementation for pilot differs slightly.• Initiated by professional• Supported with leaflet• Completed either then and their or on a later visit• Completed by the professional and the patient.• Form left with patient• Form may not be initiated if

– Patient too ill to engage with the process – Patient confused, agitated or unable to communicate for other reasons – Inappropriate time in the illness (focussing on living, in denial, refusing or overwhelmed

with bad news) – Contact time with patient too short to initiate the document appropriately– Insufficient staff time– Other (please state)

• Log documents are completed.• Fax sent to all appropriate professionals informing them that the document has

been initiated.

• Pilot project commenced 1st April 2008!• Four GP Surgeries

– Mile End– Fakenham– Blofield– Attleborough

• Two care homes– Sutherlands (Wymondham)– The Old Vicarage (Ludham)

• In-Patient unit PBL• Rowan Day Centre PBL• NNUH wards

• Locally written• Adapted PPoC Document• Patient Leaflet• Idiots guide• Checklist• Log documents• Fax forms

• Ongoing pilot• Due to cease October 2008• Should have conclusions by early 2009– Looking particularly at deaths in Preferred Place of

Care, and how preferred place of care may change over the disease trajectory.

• Plan to roll out across Central Norfolk in 2009

• What is the PPoC?– Patients making their wishes known

• What patient groups should we be using it with?– Anyone with a life limiting illness, at least initially!

• Where does it fit with GSF/LCP etc?– Start as early as appropriate, feeds into GSF meetings

• Who completes the documentation?– Ideally patient, or professional and patient

• Are there any downsides?– Of course!

• Local ACP/PPoC Documentation and pilot.– Started April 2008, due to report early 2009– May lead to wider roll out across Central Norfolk.