1. Advance Care Planning Ian d’Young Performance Improvement Team
Auckland District Health Board

2. $20.5 million!

3. Chance of winning 38 million to 1 Chance of dying guaranteed
Who has plans on what they would do with a big win?
Who shared/talked about it with your family, mates?
Whose doctor/healthcare team knows what is important to them?
Do they know what care and treatment you might want as you approach the end of your life?
Who knows what their partner’s care preferences are?
Who has PoA of personal care & welfare for someone else.
Do you know what that person wants, what their values and beliefs are?
Would you be able to make a decision for them that they would have wanted for themselves?
Everyone has a story – 10 to 1 are bad stories….

4. What is the problem?
Clinicians don’t know what is important to the patient Ratio of positive experience: negative is 1:10 Most of us don’t talk about it until it’s too late Huge stress for patients, families and clinicians
Talking to this slide - It has been shown that we tend to over treat and provide care that patients with terminal illness don’t want and often don’t need.

5. A question to clinicians…
How many times have you thought “…if only”?
Talking to this slide - It has been shown that we tend to over treat and provide care that patients with terminal illness don’t want and often don’t need.

6. What is Advance Care Planning
ACP is a process of discussion and shared planning for future health care. It involves the patient, whanau and health care professionals.
ACP gives patients the opportunity to develop and express their preferences for future care based on:
their personal views, culture and values
a better understanding of their current and likely future health
the treatment and care options available.
Talking to this slide : Discuss the evolution of ACP – from DNR orders made by clinicians to DNR - decisions made in consultation with the patient – drive to have patients make decisions in advance (advance directives) still with the focus of transfer of treatment decision-making to the patient – advance care planning where the value is in shared decision-making and conversations, where a plan or advance directive is not the only outcome of the process. It is now focused on bring people together to talk about end of life and future care possibilities.
DNR – evolution process

7. Talking with family, loved ones and the care team or GP is important
It’s a process
ACP needs to be introduced early enough for people to have lots of time to think about, talk about and document their wishes
Talking with family, loved ones and the care team or GP is important
If a person changes their mind or their circumstances change, simply update the ACP…it’s not set in stone
DNR – evolution process

8. Urgent need to break through the barriers to improving care:
Why is ACP important?
Urgent need to break through the barriers to improving care:
Talking to this slide - CONSUMERS – we have an aging population dying from chronic illness complications or frailty. Couple of decades ago death was clearly part of living, we died in the community - this has also changed – death and dying are largely taboo. The deep and powerful fact of death is that we naturally go to lengths to avoid until we have to, and sometime not even then – death denying instincts of us all are intrinsic in our make up, part of our survival DNA and we are right to tread carefully in this area and not demean its significance. The flip side of this is that people are dying unprepared.
Survival DNA

9. Urgent need to break through the barriers to improving care:
Why is ACP important?
Urgent need to break through the barriers to improving care:
Talking to this slide With the advent of modern medicine and medical advancement, we can keep some people alive indefinitely, stay off death. In the not too distant past, people generally died more suddenly from infection or accident. Dying has not become an issue that requires a diagnosis. We are not effectively communicating diagnosis and prognosis, we often avoid it because we believe that it will adversely affect chronic disease self management and/or strip the patient of hope. Studies have shown that this is in fact not the case for most people.
Diagnosis, etc

10. Better communication across the sector
Why is ACP important?
Better communication across the sector
Talking to this slide With the advent of modern medicine and medical advancement, we can keep some people alive indefinitely, stay off death. In the not too distant past, people generally died more suddenly from infection or accident. Dying has not become an issue that requires a diagnosis. We are not effectively communicating diagnosis and prognosis, we often avoid it because we believe that it will adversely affect chronic disease self management and/or strip the patient of hope. Studies have shown that this is in fact not the case for most people.
Diagnosis, etc

11. An Advance Care Plan is a record of a person’s wishes, preferences, values and goals relevant to future care and could include an advance directive
What else could it include?
An advance care plan is an articulation of wishes, preferences, values and goals relevant to all
current and future care.

12. Changing outcomes

13. Consumer barriers
People are thinking about and touching on it in casual conversation
Most don’t know they can influence the outcome
They want healthcare workers to
bring it up

14. …and they want to talk about it early

15. DIAGNOSIS and DISEASE MANAGEMENT
If something unexpected occurred, are there circumstances where you would prefer treatment to shift to comfort and natural death? Does person have an EPoA
Diagnosis, acute episodes, decline in function
Painting a picture of what the future might hold with regard to disease progression.
Traditional ACP
Person at risk of dying in the next 12 months
Detailed Planning and documentation of treatment & care
preferences
Before a person is “diagnosed”, understanding what is important to the person and encouraging thinking about planning generally
DIAGNOSIS and DISEASE MANAGEMENT
EARLY
AT RISK

16. Information and resources
Community
Media coverage
Messaging
Info resources
Website
Conversations that Count project

17. Information and resources
Community
Media coverage
Messaging
Info resources
Website
Conversations that Count project

18. Workforce barriers SKILLS and CONFIDENCE Not sure how to raise it
Not sure whether to talk to the patient or their family
Might get out of my depth – skill or knowledge
Uncomfortable talking about it myself
I don’t know how to raise it with someone who might have different cultural beliefs and values to me
Not sure what to do with the information they will give me
_________________________

19. Workforce barriers www.advancecareplanning.org.nz
To find out more about our online training, courses and access our films and other resources, visit:
SKILLS and CONFIDENCE
Not sure how to raise it
Not sure whether to talk to the patient or their family
Might get out of my depth – skill or knowledge
Uncomfortable talking about it myself
I don’t know how to raise it with someone who might have different cultural beliefs and values to me
Not sure what to do with the information they will give me
_________________________

20. It’s good to share If clinicians can’t see it, it’s of no value
Advise sharing of ACP with:
EPA
Family, spouse or trusted person
GP/ Primary Care
Secondary care (hospital record)
Lawyer

21. It’s good to share
People can send their ACP to be scanned to their hospital record at ADHB where an alert will be created

22. An alert on the hospital record

23. So how do I get started?

24. What do I need to do as a leader?
Empower the team Mandate team to do online training Add it to your MOS board

25. What do I need to do as a clinician?
Assess the right patient Choose the right time Get help when you need it

26. What do I need to do as a clinician?
Document it to enable the next clinician

27. Documenting an ACP Conversation
The CR8989 are ordered in pads of 50 through the normal Oracle stock orders
Can be brief documentation
Added to other ACP documentation in 3M

28. What do I need to do as a clinician?
Include reference to it in discharge letter to enable primary care/ ARCs to follow up

29. Getting started: Top tips
Watch the film online Complete the 4 level 1 Moodle Modules Place an ACP form in the front of each set of notes with the care plans Add it to the ward MOS board

30. And finally…

33. Conversation Starters

34. Conversations that Count Training

35. To find out more about our online training, courses and access our films and other resources, visit:
SKILLS and CONFIDENCE
Not sure how to raise it
Not sure whether to talk to the patient or their family
Might get out of my depth – skill or knowledge
Uncomfortable talking about it myself
I don’t know how to raise it with someone who might have different cultural beliefs and values to me
Not sure what to do with the information they will give me
_________________________