MCGP Dr Rachel Wiseman

Presentation outline Decision making in non-competent patients Setting the scene for MCGP The Medical Care Guidance Plan What next…..

Decision making in non-competent patients

Decision Making Cascade: What happens when a person is no longer competent? Valid advance directive EPoA (cannot withhold standard life-sustaining treatment) Ascertainable preferences – apply patient preference Best interests - other suitable people (Right 7:4) Just to reiterate this point I have included this slide. Where a patient decision sits in relations to the families wishes is often something that gets asked during these presentations. E.g. What happens if the family are demanding the patient is actively treated 1 : Has the person already made a decision to consent or refuse - Advance Directive – - how confident is the health professionals that it is valid If not 2: Is there someone else who has legal right to make the decision on this person’s behalf ? activated EPoA for health and welfare / welfare guardian. NB: EPoA has restricted decision making rights – they cannot withhold standard treatment/procedure intended to save person’s life or to prevent serious damage to their health. 3: The clinician must step into the shoes of the individual and use whatever information they can elicit to make the decision in the best interests of the patient - based on ascertainable views of patient (ACP, questionable AD, other notes/discussions) - may involve “non invoked” EPoA – other Whanau – carers – professionals involved in their care - etc 4: If none of the above, clinician makes the decision in the patient’s best interests ROLE of an ACP – To contain the AD, to say who the EPoA is ; to give preferences and values to help the clinician and Whanau Medical decision-making Adapted from the National Advance Care Planning Cooperative ‘s Training Program Resources

Code of rights 7 (4) 4) Where a consumer is not competent to make an informed choice and give informed consent, and no person entitled to consent on behalf of the consumer is available, the provider may provide services where - a) It is in the best interests of the consumer; and b) Reasonable steps have been taken to ascertain the views of the consumer; and c) Either, - i. If the consumer's views have been ascertained, and having regard to those views, the provider believes, on reasonable grounds, that the provision of the services is consistent with the informed choice the consumer would make if he or she were competent; or ii. If the consumer's views have not been ascertained, the provider takes into account the views of other suitable persons who are interested in the welfare of the consumer and available to advise the provider

Health care proxy Enduring Power of Attorney – if invoked Court appointed Welfare Guardian Cannot withhold standard treatment/procedure intended to save person’s life or to prevent serious damage to their health Unique to NZ

Decision making Ultimately rests with the healthcare team, usually the GP Extremely difficult for a locum or after hours GP to make treatment decisions for patients not well known to them Often acting with scanty background information in times of crisis

Capacity assessment Coming to a HealthPathways site near you…..

Setting the scene for MCGP

Place of Death 2000-2010 30% of deaths take place in ARC, more so as population ages 34.2% in hospital, 30.7% in residential care and 22.3% in private residence. (For deaths over age 85, 54.8% in residential care and only 9.9% in private residence) Source: Analysis of Ministry of Health MORT data 2000 to 2010

Historic Deaths and Future Projections by Age Band Deaths will change in their distribution across age groups. Expected to be a continued decline in deaths under age 65 and age 65-74, with a dramatic increase in the number of deaths over age 85. Source: Palliative Care Council, Working Paper No. 1, July 2013. Drawn using data from Statistics New Zealand; personal communication Joanna Broad.

Many of those in ARC have fluctuating or permanent loss of decision making capacity ARC requirements around documentation including DNACPR No national standards around documentation

We are all guilty of criticising the absence of clear decisions around EOL care and hospitalisation in those who lack capacity BUT, there is no clear process around having the discussion, securing the right information and documenting it

Been involved with integration of ACP in CDHB ACPlans all reviewed for clinical relevance before publishing ACPlans being submitted on behalf of others who were not competent to make healthcare decisions

Why not? The elephant in the room… Infrastructure and support networks available to implement a process around decision making in those who lack capacity So we took a deep breath…..

The Medical Care Guidance Plan

Aiming to capture The thoughts of the person The thoughts of those close to the person The appropriate level and goals of medical care The discussions that have taken place around this Any divergent viewpoints

4 sections 1. Decision making competence Conditions leading to permanent inability to make healthcare decisions Signed by senior healthcare professional

2a. Presence of decision making authority Details of EPoA or Welfare Guardian Lists who else is required to be consulted Specifies if the patients condition and prognosis has been discussed with the proxy decision maker 2b. Absence of decision making authority Names of those close to the person and their thoughts on the patients likely wishes Documents any discrepancies between family members and the doctor completing section 4

3. Personal health information Current medical conditions and treatments Current level of function Expected disease progression and prognosis If prognosis has been discussed with the patient to their level of competence, and what weight should be given to these views

4. Medical care guidance To be completed by a doctor Guidance is advisory only Documented if decision is enduring and planned review date Resuscitation status is clear

Trial of MCGP 6 ARC facilities trialed the form All had some patients with dementia External auditors monitored use and provided feedback Final alterations being made before rollout

What next…. Will be rolled out in CDHB Hopefully will become more prevalent in the yellow envelopes Subsidy available for plans submitted to ACP admin Will be taken to HOPSLA group for review

Healthinfo – some great info for relatives Healthinfo – some great info for relatives. Also healthpathways site including info re subsidy