ACPACPAdvance Care PlanningAdvance Care Planning

Claud RegnardClaud Regnard

ororAcutely Confused Acutely Confused Plans?Plans?

What’s the background?What’s the background?

When a patient lacks capacityWhen a patient lacks capacity- wishes can be difficult to ascertain- wishes can be difficult to ascertain- collapse demands a quick decision- collapse demands a quick decision

So, the apparent answer isSo, the apparent answer is-a decision made in advance-a decision made in advance

Many guidelines eg. GMC, BMA/RC/RCNMany guidelines eg. GMC, BMA/RC/RCNMental Capacity ActMental Capacity Act

Extensive restructuring of decisionsExtensive restructuring of decisions

Largely ignoredLargely ignored

PaulPaul

Paul is a 68yr man with severe, Paul is a 68yr man with severe, irreversible COPD & emphysema irreversible COPD & emphysema

On ventilator in ITU for past monthOn ventilator in ITU for past month Low SaOLow SaO22 Asking for ventilator to be switched offAsking for ventilator to be switched off His greatest fear is gasping for breathHis greatest fear is gasping for breath Possibility that he will survive for 1-5 Possibility that he will survive for 1-5

days after stopping ventilatordays after stopping ventilator Staff views vary in need to treatStaff views vary in need to treat

Paul Paul Next steps?Next steps?

Does he want to discuss future care?Does he want to discuss future care? Capacity: two stagesCapacity: two stages

Stage 1: assume capacity Stage 1: assume capacity unlessunlessthere is an impairment or disturbance of there is an impairment or disturbance of mind or brainmind or brain- if this is suspected, go to Stage 2- if this is suspected, go to Stage 2

Paul was hypoxic and had a low moodPaul was hypoxic and had a low mood

Paul Paul Assessing capacity Assessing capacity

Stage 2Stage 21.1. Can they understand the information?Can they understand the information?

NB. Must be imparted in a way they understandNB. Must be imparted in a way they understand

2.2. Can they retain the information?Can they retain the information?NB. Only needs to be long enough to use and NB. Only needs to be long enough to use and weigh up the informationweigh up the information

3.3. Can they weigh up that information?Can they weigh up that information?NB. Must be able to show they can consider the NB. Must be able to show they can consider the benefits and burdens of the proposed benefits and burdens of the proposed treatmenttreatment

4.4. Can they communicate their decision?Can they communicate their decision?NB. Carers must try every method to enable thisNB. Carers must try every method to enable this

Despite hypoxia and low mood, Paul had the Despite hypoxia and low mood, Paul had the capacity to decide his future carecapacity to decide his future care

PaulPaulNB previous Advance Decision to Refuse NB previous Advance Decision to Refuse

Treatment (ADRT) and Lasting Power of Treatment (ADRT) and Lasting Power of Attorney (LPA) are irrelevant as latest Attorney (LPA) are irrelevant as latest decision countsdecision counts

Preparing an ADRTPreparing an ADRT- discuss principles- discuss principles- consider what needs to be included- consider what needs to be included- allow time to consider ADRT and communicate - allow time to consider ADRT and communicate with family (NB. they cannot consent)with family (NB. they cannot consent)- must be written if refusing life-saving Rx- must be written if refusing life-saving Rx

ADRT for Paul written refusingADRT for Paul written refusing- ventilation & CPR (including a DNACPR)- ventilation & CPR (including a DNACPR)- nutrition & hydration- nutrition & hydrationbut allowing any drugs needed for comfortbut allowing any drugs needed for comfort

PaulPaul

OutcomesOutcomes ADRT refusing vent / CPR /hydrationADRT refusing vent / CPR /hydration

DNACPR form completedDNACPR form completed After 48hrs consideration and discussion After 48hrs consideration and discussion

with clinicians and family, Paul desperate with clinicians and family, Paul desperate to get startedto get started

Midazolam started in the morning at Midazolam started in the morning at 1mg/hr 1mg/hr - ADRT now active- ADRT now active

Ventilator withdrawn in stages, Ventilator withdrawn in stages, midazolam increased up to 3mg/hr midazolam increased up to 3mg/hr

Ventilator stoppedVentilator stopped Died peacefully 18hrs after ventilator Died peacefully 18hrs after ventilator

stoppedstopped

TerryTerry

41 yr old man with recurrent oral Ca41 yr old man with recurrent oral Ca Past and present high alcohol intakePast and present high alcohol intake Good social and verbal skillsGood social and verbal skills Agreed to surgery, signed consentAgreed to surgery, signed consent On day of surgery became frightened, On day of surgery became frightened,

asking why he was in hospital and asking why he was in hospital and insisted on returning homeinsisted on returning home

Surgeons refusing to reschedule in case Surgeons refusing to reschedule in case he refuses againhe refuses again

TerryTerry

CapacityCapacityUnderstood informationUnderstood informationRetained it long enough to weigh upRetained it long enough to weigh upAble to communicate backAble to communicate back‘If I don’t have the op, it’ll get bigger and ‘If I don’t have the op, it’ll get bigger and spread.’spread.’

……but unable to weigh details of risks and but unable to weigh details of risks and burdens of surgeryburdens of surgery

Has severe alcoholic dementia with sparing Has severe alcoholic dementia with sparing of speechof speech

TerryTerry

Issues to consider:Issues to consider: Did Terry make an ADRT when he had Did Terry make an ADRT when he had

capacity?capacity? Did he empower someone to be a Lasting Did he empower someone to be a Lasting

Power of Attorney for Health and Welfare?Power of Attorney for Health and Welfare?- if so did this empowerment include the - if so did this empowerment include the ability to make decisions about life-saving ability to make decisions about life-saving treatment?treatment?

NB. Most recent order countsNB. Most recent order counts

TerryTerryBest interestsBest interests Appoint decision-maker who shouldAppoint decision-maker who should- Set up a best interests meetingSet up a best interests meeting- Include the patient if possibleInclude the patient if possible- Identify all relevant circumstancesIdentify all relevant circumstances- Find out patient’s previous views (ACP)Find out patient’s previous views (ACP)- Consult, consult, consultConsult, consult, consult- Minimise restricting the patient’s rightsMinimise restricting the patient’s rights- Decide in their best interestsDecide in their best interests- Document, review, document, review.......Document, review, document, review.......

TerryTerry

OutcomeOutcome Surgery rescheduledSurgery rescheduled Terry in agreement to go aheadTerry in agreement to go ahead Form 4 consent signed by psychiatrist and Form 4 consent signed by psychiatrist and

surgeonsurgeon Surgeons reminded they regularly operate Surgeons reminded they regularly operate

on patients who make it clear they do not on patients who make it clear they do not want surgery (children)want surgery (children)

Plan made to sedate in HDU for 24hrs Plan made to sedate in HDU for 24hrs post oppost op

Despite not being sedated and striking Despite not being sedated and striking nurse on waking, he recovered rapidly nurse on waking, he recovered rapidly and returned to EMI homeand returned to EMI home

In an emergencyTreat if this will

benefit the patient

Person-centred Carebased on a continuing dialogue with the individual

(at their pace and under their control)

Contingency or

Emergency care plan

Mental Capacity Act:Best Interests processinformed by an Advance

Statement or instructed by an ADRT or LPA

If an emergency is anticipated

Mental Capacity Act:Advance Statement Personal Welfare LPAADRT

If capacity is still present but a loss of capacity is anticipated

The decision of the individual with capacity

usually takes precedence over any other decision

If capacity has been

lost

If capacity has been

lost

A clinical decision A clinical decision frameworkframeworkwww.resus.org.uk/pages/dnar.htmwww.resus.org.uk/pages/dnar.htm

Is an arrest NOT a possibility in the Is an arrest NOT a possibility in the present circumstances?present circumstances? = no decision= no decision

Is there a realistic chance that CPR Is there a realistic chance that CPR COULD be successful?COULD be successful?= obtain consent for CPR= obtain consent for CPR

Is there a realistic chance that CPR Is there a realistic chance that CPR CANNOT be successful?CANNOT be successful?= AND (Allow Natural Dying)= AND (Allow Natural Dying)