Post on 09-Jun-2015
description
Recognising the Dying Patient
Developing new systems for
end of life care
Little Company of Mary Health Care Limited
Sue Hanson National Director Clinical Services Little Company of Mary Health Care IIR Conference Managing the Deteriorating Patient Melbourne 17 September 2013
Little Company of Mary Health Care
Catholic Health, Aged & Community Service Provider
Calvary Care
Specialist Palliative Care Services (6)
Public Hospitals (4)
Private Acute Care Hospitals (11 + 2 Day surgeries)
Residential and Community Aged Care Services (15)
Community Support Services (28 offices)
Provide Services in
ACT, NSW, SA, VIC, NT
Calvary Hospitals and Services
A word on language
In this presentation I use these terms to mean the following
End of life
Period when a person is living with advanced, progressive life limiting illness
Differentiated by „Surprise‟ question (Lynne, 2000)
CAPC Screening Criteria for at risk patients
Palliative Care
Designated specialist services provided to people who are approaching or reaching the end of life who have complex needs
Dying
The period of time when a person‟s end of life is imminent (i.e. 0-72 hours prior to death).
143,900 people will die each year in Australia1
52+% of deaths will occur in acute care hospitals3
40% of these people will die in an ICU4
7.8 (mean) hospital admissions in last year of life5
Average 5.6 days LOS
70% visited ED
mean attendances 1.7 Cancer / 2.5 non-cancer5
75% of these deaths are clinically „expected‟2
70% of people want to die at home3
‘Burning Deck’
Care in the last year of life
People over 70 have a 30% higher chance of dying or being severely disable within a year of a major operation
In 2002 people in the last year of life consumed 801,437 bed days in NSW – 10.3% of all bed days
Care in last year of life accounted for $470.6 M (2002 $) in inpatient costs – 20% of all costs for those aged >65
Forecast threefold increase in real healthcare and residential expenditure in FY07 $ over thirty year period - $85.06b ((02/03) to $246.06b (2032/33)
2.3% of privately insured use 1/3rd of all hospital benefits
Deteriorating or dying?
Mortality in end stage chronic illness characterised by progressive deterioration
Patients who die while admitted to acute care will trigger deterioration criteria
NFR after MET 13-29% in public (Downey et al, 2008;Quach et al, 2008)
Need to have better systems to recognise end of life and dying.
Too little too late?
Forty-nine per cent of patients were recognised as dying 24 hours or less before death
17% between 24 and 36 hours before death,
21% between 36 and 72 hours before death, and
13% greater than 72 hours before death.
Heart Disease - CHF
At least two of the indicators below: • CHF NYHA stage III or IV – shortness of breath
at rest or minimal exertion • Patient thought to be in the last year of life by the
care team - the „surprise‟ question • Repeated hospital admissions with symptoms of
heart failure • Difficult physical or psychological symptoms
despite optimal tolerated therapy.
COPD
• Disease assessed to be severe e.g. (FEV1 <30%predicted – with caveats about quality of testing)
• Recurrent hospital admission (>3 admissions in 12 months for COPD exacerbations)
• Fulfils Long Term Oxygen Therapy Criteria • MRC grade 4/5 – shortness of breath after 100
meters on the level or confined to house through breathlessness
• Signs and symptoms of right heart failure • Combination of other factors e.g. anorexia,
previous • ITU/NIV/resistant organism, depression • >6 weeks of systemic steroids for COPD in the
preceding 12 months
“ an organised , deliberate approach to
the identification, assessment and management of care of people
approaching and reaching the end of life”
A redesigned systems-based
approach
Developing a systems approach
Diagnosis
Chronic
Illness
Gateway 1
EOL
Gateway 2
Imminent Dying Death
Transition Points
Years 12 months 48-72 hours Death
Patient journey approaching the end of life
Gateway 2: The focus of current system
Dx
Gateway 1
EOL
Gateway 2
Imminent Dying Death
Transition Points
Years 12 months 48-72 hours Death
Gateway 1: Redesigning better care
Dx
Gateway 1
EOL
Gateway 2
Imminent Dying Death
Transition Points
Years 12 months 48-72 hours Death
A comprehensive system of care
Dx
Gateway 1
EOL
Gateway 2
Imminent Dying Death
Transition Points
Years 12 months 48-72 hours Death
Organisation wide system – key components
The use of screening and assessment tools
Development of treatment algorithms or pathways
Development of workforce competence frameworks
Implementation of mandatory education and training units
Change management
Re-design and reform
May not be recognised as „palliative‟ or „dying‟
Use of universal screening criteria5 in primary care, acute care and emergency departments
Establish Goals of Care
EOL Communication
Understanding loss and grief
Modifying care management in line with goals of care
Recognising and responding to the person approaching the end of life (Gateway 1)
Transition points occur when there is a change in clinical condition, ED presentation or admission
Revisit and review documented goals of care
Use of common assessment tools
Review care coordination and management in line with goals of care
MOLST
Care at the transition points
Building Competence
LITTLE COMPANY OF MARY HEALTH CARE
National Palliative and End of Life Care Competence and Education Strategic Framework
National Palliative Care Collaborative
January 2012
Competency based education
ORIENTATION FOUNDATION THEORETICAL ASSESSMENT TECHNICAL SKILLS
ALL STAFF &
VOLUNTEERS
ALL STAFF &
VOLUNTEERS
LEVEL 1 Volunteers
Admin
PCA
Support Staff
Pain & Symptom Assessment &
Management
Holistic Care
Loss & Grief
Communication
Clinical Assessment
Pain Management
Communication skills
Advance Care Planning
Care of Dying Pathway
MOLST
Introduction to
mission & values of
Calvary
Communication Skills
Loss & Grief
LEVEL 2 RN
EEN
EN
Pain & Symptom Assessment &
Management
Holistic Care
Loss & Grief
Communication
Clinical Assessment
Pain Management
Communication skills
PCOC Assessment
Syringe Drivers
Advance Care Planning
Care of Dying Pathway
MOLST
LEVEL 3 Specialist Pal
Care Clinical
Staff
Multi-
disciplinary
Pain & Symptom Assessment &
Management
Holistic Care
Loss & Grief
Communication
Clinical Assessment
Pain Management
Symptom Management
Communication skills
Syringe Drivers
Medications
PCOC Assessment
Advance Care Planning
Care of Dying Pathway
MOLST
CALVARY ON LINE
TRAINING PLANS
POWERPOINT PRESENTATIONS
COMPETENCE ASSESSMENT TOOLS
High quality, appropriate care for all people approaching and reaching the end of life
Aligned with personal goals of care
Closer to home
Re-empowered health, aged and social care workforce – integration of end of life care as core competence area
Care of those approaching and reaching the end of life is everybody‟s business
Improved care coordination – less reactive , crisis-based care
Strengthened primary care services
Increased use of community support services
Increased use of outreach services – take care to the patient
Diversion from „default‟ pathways – appropriate, person-centred end of life care
Reduced ED presentations
Reduced acute care admissions at end of life
Collection and use of systems wide data and information
Whole of system approach provides comparable data (outcomes, service utilisation)
Recognising eol – what do we hope to achieve?
Because I could not stop for Death, he kindly stopped for me.
The Carriage held but just ourselves and Immortality
Emily Dickinson
LAST THOUGHTS