what does it offer? Karen J Hogg Glasgow Royal Infirmary & - - PowerPoint PPT Presentation

Anticipatory Care Planning – what does it offer?

Karen J Hogg Glasgow Royal Infirmary & Golden Jubilee National Hospital

Karen J Hogg

What is anticipatory care planning?

• Process designed to support patients living with a chronic long-term

condition to help plan for an expected change at some time in the future

• Voluntary progressive process of discussion

– Patient at a time where they have capacity to make healthcare decisions, family, and healthcare providers

• Patient held and led document

– Prompt patients and clinicians to “think ahead” – Details patients’ current & future priorities of care

• Not legally binding

– Can result in legal documentation

• DNACPR
• Wills
• Power of attorney

Time

Onset of incurable cancer

Illness trajectory associated with cancer

Functional status

Death Good Poor

Cancer

Increased need for palliative care services

Adapted from Murray, S. A et al. BMJ 2005;330:1007-1011

Time to plan

Time

Functional status

Death

Good Poor

Heart Failure

Unpredictable HF illness trajectory & “prognostic paralysis”

D D D

D = clinical decompensation Sudden cardiac death

Adapted from Murray, S. A et al. BMJ 2005;330:1007-1011

Intervention: CRT

“The physician who can foretell the course of the illness is the most highly esteemed” Hippocrates

What is needed for Medical Anticipatory Care Plan?

• Time

– Explanation and discussion

• Communication skills

– Some discussions can be or can become complex

• Support to follow up on difficult conversations
• Aware that these discussions can raise other issues not necessarily

directly related to that patient or the issues being discussed

• Communication of MACP

– Efficiently to other HCPs involved in care in 1o and 2o care – Electronic systems – Out of hours

Who should complete the Medical Anticipatory Care Plan?

• Healthcare professional

– Relationship with the patient to facilitate the appropriate conversations – Who knows most about their condition

• May need to involve others where there are

multiple co-morbidities or specific circumstances

Medical Anticipatory Care plans match preferred place

• f care & reduce hospital admissions

K Hogg & SMM Jenkins Medical Anticipatory Care Plans prevent hospital admissions European Heart Journal (2012) 33 (Abstract supplement) 483-484

Medical ACP No Medical ACP

Medical Anticipatory Care Plan in Practice

• 70yr old male

– Chronic heart failure with severe LVSD (QRSd 118ms) – Secondary prevention ICD – Multiple co-morbidities (DM, Arthritis, COPD, CKD, AF, anaemia)

• 5 Admissions over 6 months various reasons

(86 bed days)

– Pulmonary oedema & ascites – Painful cellulitic legs 2o peripheral oedema – Appropriate discharge from defibrillator – Acute on chronic renal impairment – Falls secondary to postural hypotension

Spoke with patient established priorities of care

• Preferred place of care – Home
• Did not want any further hospital admission
• Rationalised
• Switched

high dose

• ral diuretics

(bumetanide)

• Improved diuresis with bumetanide
• Reduction in gut oedema + prokinetic

improved nausea and appetite

• Breathlessness improved with
• xynorm which also improved pain

control from arthritis

• Aqueous cream + menthol & oral

balance gel for dry skin and mouth

HOME FU: HF&SC clinic HFLN service at home Day services local hospice with his wife Medical Anticipatory Care plan

ICD Symptom Management Medical Rx

• Reprogrammed
• Established his

thoughts regarding previous discharges from his ICD

Outcome

• 4 months following discharge from hospital

– Primarily home care with help of GP/DN and HFLN service guided by medical ACP – Attended HF&SC clinic at GRI

• Optimised heart failure medication
• Managed cardiac & non-cardiac symptoms
• Ongoing discussions re timing of device deactivation
• Made alterations to MACP

– Attended and benefited from day services at local hospice – No hospital admissions – No discharges from ICD

Outcome

• 5 months following discharge from hospital

– Losing weight & developing cahexia – Increasing symptom burden – Spending more time in bed – ICD was deactivated electively as planned – Developed resistant painful ascites despite high dose oral diuretics – Short admission to local hospice to allow for some ascitic fluid to be drained to relieve symptoms

Outcome

• 6.5 months following discharge from hospital

(Hospital bed days = 0)

– Died comfortably at home with family supported by HFLN service, community palliative care and GP – No further hospital admissions – No further discharges from device – Death was not a surprise and the family felt supported – GP provided bereavement care – Wife continued to attend local hospice for support for several months following his death

Karen J Hogg