Dr Karen Detering, Austin Health: Advanced Care Planning and HITH

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Information about Dr Karen Detering, Austin Health: Advanced Care Planning and HITH
Health & Medicine

Published on March 10, 2014

Author: informaoz

Source: slideshare.net

Description

Dr Karen Detering, Respiratory Physician & Clinical Ethicist - Respecting Patient Choices Program, Austin Health delivered this presentation at the 2013 Hospital in the Home conference. This 2-day event is a nurse oriented program to improve HITH services and maximise hospital efficiency. For more information about the annual event, please visit the conference website: http://www.communitycareconferences.com.au/hospitalinthehome

Advance care planning Do we really know what our patients want & do we respect it? Dr Karen Detering Respecting Patient Choices Program Austin Health karen.detering@austin.org.au

Mr K, aged 62 • Separated, wife lives nearby, 5 children • Medical history • Severe COPD • Ischaemic cardiomyopathy • Undertook advance care planning Dec 09 • Son appointed as substitute decision-maker • Completed ACP electing to have “trial” of life-sustaining treatment

Mr K continued.... • 2010 - 3 admissions - exacerbations COPD • Early 2011 – 2 admissions – exacerbations COPD • September 2011 • Presented with exacerbation of COPD • Managed on ward, deteriorated • Intubated, ICU for 3 days • no reversible factors identified • patient extubated • 1/7 later, died on ward with sons, and wife present

Impact of advance care planning for Mr K • Family very happy with care received • Staff felt comfortable • Clear plan of management • No conflict • Reduced staff time required to manage patient and family • Staff happy with outcome as they knew patient wishes followed

Mr G, 81 YO • lives with wife, 3 children • Pulmonary fibrosis – diagnosed in July 2011 • treated - steroids & oxygen. Poor response to Rx • increasing SOB, and oxygen requirements. • Recurrent infection requiring IV antibiotics • ACP was introduced. July 2011 – he declined • In January 2012 he was approached again: • Not for intubation / Not for ICU • Not wishing further hospitalisation

Mr G Continued ….. • He discussed his wishes with his GP, and documented his wishes. • Wife as his substitute decision maker • Subsequently became unwell - infection & SOB • GP called, not ambulance (as he would have previously done) • Died at home with family present

Background – medical decision-making • Competent patients can refuse unwanted medical interventions, even if death is the likely outcome • This is well established ethically and legally in the practice of modern medicine • Ethical principles: • Autonomy & Informed consent • Beneficence vs. non maleficence • Dignity & Respect

Decision-making in non competent patients • Substitute decision maker • Decision making guided by • Previously completed Advance Care Plan • “Substituted judgement” –aim to reach the decision patient would reach if competent • Consideration of the patient’s “best interests”

What Is Advance Care Planning? • Advance care planning: • Assists patients to reflect on their values and beliefs in relation to their goals of medical care • Encourages patients to • Appoint a substitute decision maker & discuss their wishes with this person • Document their future treatment wishes • Only comes into effect if the person becomes unable to make their own decisions

Why is ACP important? • Most people die after chronic illness • 80% of deaths occur under medical care & ~ 50% not competent when near death • Family & friends – significant chance of not knowing our views without discussion • A doctor who is uncertain will, with good intention, treat aggressively  People being kept alive under circumstances that are not dignified, and in way they would not have wanted

Coordinated ACP: • Trained non medical staff facilitate ACP • Work closely with patient’s health care team • Assist patients / relatives to reflect on patient’s goals, values and beliefs • Encourage appointment of SDM and documentation of wishes • Uses current legislation • Makes sure documents are clear and available

Building the evidence

Randomised controlled trial of ACP • English speaking, competent patients ≥ 80YO • Main diagnosis - Cardiac / Respiratory • Intervention – coordinated ACP • 81% patients completed ACP • 86% expressed wish re end-of-life care • 82% wish re CPR, 75% wish re LPT • Family involved – 74%, ↑ likelihood of completing ACP • Average time taken - 64 minutes

What happened to decisions after ACP? Cardiopulmonary Resuscitation Yes Y- DOO Pre ACP (%) Post ACP (%) No 27 3 38 47 23 31 Delegate Don’t know 0 18 12 1 Life-prolonging Treatment Yes Y- DOO Pre ACP (%) Post ACP (%) No 67 2 22 33 9 37 Delegate Don’t know 0 24 2 4

Wishes regarding CPR? Cardiopulmonary Resuscitation Yes Y- DOO Pre ACP (%) Post ACP (%) No 27 3 38 47 23 31 Delegate Don’t know 0 18 12 1 Life-prolonging Treatment Yes Y- DOO Pre ACP (%) Post ACP (%) No 67 2 22 33 9 37 Delegate Don’t know 0 24 2 4

Wishes regarding life-prolonging treatment? Cardiopulmonary Resuscitation Yes Y- DOO Pre ACP (%) Post ACP (%) No 27 3 Delegate Don’t know 38 47 23 31 0 18 12 1 Life-prolonging Treatment Yes Y- DOO Pre ACP (%) Post ACP (%) No 67 2 Delegate Don’t know 22 33 9 37 • move to less aggressive treatment • delegation of decision making 0 24 2 4

Other results: • ACP patients more likely to be satisfied regarding • overall hospitalisation & information provided • being listed to • level of involvement in decision making • their own / their family

Other results: • Control patients- negative comments • the doctors don’t listen • I felt ignored and in the way • They don’t want me as I am too old • They wouldn’t speak to me, and kept discussing things with my family

Deceased patients • Primary outcome measure: • Patient’s wishes known and respected • Intervention 86% • Control 30% p < 0.001 • No difference in mortality between groups • Location of death • ICU: 0 intervention pt, 4 control pt (p = 0.03)

Impact of death on surviving relatives • Death of a relative can cause significant anxiety, depression and post-traumatic stress • How do you quantify the impact? • IES: Impact of Event Score • HADS: Hospital Anxiety & Depression Score

Deceased patients (56 patients) Intervention Number of people with IES > 30 Number of people with HADS – depression > 8 Number of people with HADS – anxiety > 8 FM’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % FM’s perception of patient’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % Control P value 0 4 0.03 0 8 0.002 0 5 0.02 0.02 24, 82.8% 2, 6.9% 3, 10.3% 13, 48.1% 8, 29.6% 6, 22.2% <0.001 25, 86.2% 1, 3.4% 3, 10.3% 10, 37.0% 10, 37.0% 7, 25.9%

Deceased patients (56 patients) Intervention Number of people with IES > 30 Number of people with HADS – depression > 8 Number of people with HADS – anxiety > 8 FM’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % FM’s perception of patient’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % Control P value 0 4 0.03 0 8 0.002 0 5 0.02 0.02 24, 82.8% 2, 6.9% 3, 10.3% 13, 48.1% 8, 29.6% 6, 22.2% <0.001 25, 86.2% 1, 3.4% 3, 10.3% 10, 37.0% 10, 37.0% 7, 25.9%

Deceased patients (56 patients) Intervention Number of people with IES > 30 Number of people with HADS – depression > 8 Number of people with HADS – anxiety > 8 FM’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % FM’s perception of patient’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % Control P value 0 4 0.03 0 8 0.002 0 5 0.02 0.02 24, 82.8% 2, 6.9% 3, 10.3% 13, 48.1% 8, 29.6% 6, 22.2% <0.001 25, 86.2% 1, 3.4% 3, 10.3% 10, 37.0% 10, 37.0% 7, 25.9%

Deceased patients (56 patients) Intervention Number of people with IES > 30 Number of people with HADS – depression > 8 Number of people with HADS – anxiety > 8 FM’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % FM’s perception of patient’s satisfaction with the quality of death Very satisfied: n, % Satisfied: n, % Not satisfied, n. % Control P value 0 4 0.03 0 8 0.002 0 5 0.02 0.02 24, 82.8% 2, 6.9% 3, 10.3% 13, 48.1% 8, 29.6% 6, 22.2% <0.001 25, 86.2% 1, 3.4% 3, 10.3% 10, 37.0% 10, 37.0% 7, 25.9%

Survey of surviving family members “He had a very peaceful death, just as it should have been, & I would like to thank all staff for this.” “Even though we already knew what he wanted it was great to be able to talk about it so openly.” _____________________________________________ “Mum didn’t want heroics. I was horrified to hear she received 45 minutes of CPR. She didn’t want it. All anyone had to do was ask.” “The doctors kept asking if dad should be resuscitated. I didn’t think they should keep asking, as they also told us it wouldn’t help him. It was obvious to us he was dying.”

Benefits of ACP • ACP improves end of life care and patient satisfaction with care • ACP assists family to: 1. know patient wishes, be involved in ACP discussions • More able to make decisions • Less burdened 2. Have less risk of stress, anxiety and depression 3. Be more satisfied with quality of patient’s death

Illness trajectories

Illness trajectories Erratic e.g. organ failure – COPD

Illness trajectories Erratic e.g. organ failure – COPD

ACP in patient with chronic / life limiting illness • Hope for the best/ plan for the worst • Determine patient’s treatment preferences during an acute exacerbation/ deterioration • Consider a “trial of treatment” if appropriate • Reassure that discussing ACP • Will not diminish focus on maximizing outcomes (incl. survival if this is a goal) • limiting LPT does not equate to limiting care • discuss a commitment to non abandonment

ACP - the present and the future • ACP – should be part of routine health care • Acute, sub acute, GP, community, aged care, well elderly • Incorporated into hospital standards, government policy • All health care staff need to be aware of concepts, know what to do if patient has ACP, how to respond to requests for ACP

www.respectingpatientchoices.org.au

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