ACP Advance Care Planning Claud Regnard or Acutely Confused Plans?

What’s the background? l When a patient lacks capacity - wishes can be difficult to ascertain - collapse demands a quick decision So, the apparent answer is -a decision made in advance Many guidelines eg. GMC, BMA/RC/RCN Mental Capacity Act Extensive restructuring of decisions Largely ignored

Paul l Paul is a 68yr man with severe, irreversible COPD & emphysema l On ventilator in ITU for past month l Low SaO 2 l Asking for ventilator to be switched off l His greatest fear is gasping for breath l Possibility that he will survive for 1-5 days after stopping ventilator l Staff views vary in need to treat

Paul Next steps? l Does he want to discuss future care? l Capacity: two stages Stage 1: assume capacity unless there is an impairment or disturbance of mind or brain - if this is suspected, go to Stage 2 Paul was hypoxic and had a low mood

Paul Assessing capacity Stage 2 1. Can they understand the information? NB. Must be imparted in a way they understand 2. Can they retain the information? NB. Only needs to be long enough to use and weigh up the information 3. Can they weigh up that information? NB. Must be able to show they can consider the benefits and burdens of the proposed treatment 4. Can they communicate their decision? NB. Carers must try every method to enable this Despite hypoxia and low mood, Paul had the capacity to decide his future care

Paul NB previous Advance Decision to Refuse Treatment (ADRT) and Lasting Power of Attorney (LPA) are irrelevant as latest decision counts l Preparing an ADRT - discuss principles - consider what needs to be included - allow time to consider ADRT and communicate with family (NB. they cannot consent) - must be written if refusing life-saving Rx l ADRT for Paul written refusing - ventilation & CPR (including a DNACPR) - nutrition & hydration but allowing any drugs needed for comfort

PaulOutcomes l ADRT refusing vent / CPR /hydration DNACPR form completed l After 48hrs consideration and discussion with clinicians and family, Paul desperate to get started l Midazolam started in the morning at 1mg/hr - ADRT now active l Ventilator withdrawn in stages, midazolam increased up to 3mg/hr l Ventilator stopped l Died peacefully 18hrs after ventilator stopped

Terry l 41 yr old man with recurrent oral Ca l Past and present high alcohol intake l Good social and verbal skills l Agreed to surgery, signed consent l On day of surgery became frightened, asking why he was in hospital and insisted on returning home l Surgeons refusing to reschedule in case he refuses again

Terry Capacity Understood information Retained it long enough to weigh up Able to communicate back ‘If I don’t have the op, it’ll get bigger and spread.’ …but unable to weigh details of risks and burdens of surgery Has severe alcoholic dementia with sparing of speech

Terry Issues to consider: l Did Terry make an ADRT when he had capacity? l Did he empower someone to be a Lasting Power of Attorney for Health and Welfare? - if so did this empowerment include the ability to make decisions about life-saving treatment? NB. Most recent order counts

Terry Best interests l Appoint decision-maker who should - Set up a best interests meeting - Include the patient if possible - Identify all relevant circumstances - Find out patient’s previous views (ACP) - Consult, consult, consult - Minimise restricting the patient’s rights - Decide in their best interests - Document, review, document, review

TerryOutcome l Surgery rescheduled l Terry in agreement to go ahead l Form 4 consent signed by psychiatrist and surgeon l Surgeons reminded they regularly operate on patients who make it clear they do not want surgery (children) l Plan made to sedate in HDU for 24hrs post op l Despite not being sedated and striking nurse on waking, he recovered rapidly and returned to EMI home

In an emergency Treat if this will benefit the patient Person-centred Care based on a continuing dialogue with the individual (at their pace and under their control) Contingency or Emergency care plan Mental Capacity Act: Best Interests process informed by an Advance Statement or instructed by an ADRT or LPA If an emergency is anticipated Mental Capacity Act:  Advance Statement  Personal Welfare LPA  ADRT 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

A clinical decision framework l Is an arrest NOT a possibility in the present circumstances? = no decision l Is there a realistic chance that CPR COULD be successful? = obtain consent for CPR l Is there a realistic chance that CPR CANNOT be successful? = AND (Allow Natural Dying)