3 What is an holistic assessment? Definition of ‘holistic’An holistic assessment is one which not only looks at the physical aspects of a person, but looks also at the psychological, social and spiritual aspects
4 Holistic assessment Is a continuous process & leads to: More effective care and treatment of symptomsMore client-centred (client’s priority)Improves communication between all professionals involved with careImproves evaluation of treatmentsReassures/includes client’s familyImproves the client’s quality of life
5 The whole person?PHYSICALPSYCHOLOGICALSPIRITUALSOCIAL
6 An example is ‘total pain’ Emotional &PsychologicalPhysical‘TOTAL PAIN’SocialPersonal & Spiritual
8 Case studyEloise Griffiths is a 68 year old lady with severe heart failure. She lives with her husband, Eric, who has advancing dementia. Eric was the sole carer for Eloise until 2 years ago when he was diagnosed with Alzheimer’s Disease. He remains independent, but his son and daughter have noted that he is getting confused at times.As part of a package to increase the support for Eric, to enable him to stay at home and to care for Eloise, you have been asked to provide two visits per day, one morning to help Eloise get up and one in the evening to assist her to bed. The referral you received says the Eloise has a very limited life expectancy and that there are no other medical alternatives to managing her heart failure. She gets extremely breathless on the minimum of movement and requires continuous oxygen.This lady is at the end of her life (if you had a register she would be ‘Amber’). Considering the above issues, how do you carry out your assessment, both generally and in relation to potential end of life issues?Using a care planning template, consider the four following areas:PhysicalPsychologicalSpiritualSocial
11 Help with assessmentsWhat questions should you ask?
12 Ask…. Nature – what is it like Location – where do you get it Severity – what is it like at its worstFrequency – how often do you get thisDuration – how long does it lastTriggers – does anything bring it on/ make it worseAlleviating factors – does anything relieve itAssessment tools useful e.g. body charts, symptom diaries.
13 Observing behaviour Sweating Loss of appetite/fluid intake Guarding Urinary & faecal incontinenceSleep disturbanceIncreased confusionFacial expressionAssuming a foetal positionAgitationIncreased/decreased movementwithdrawalHard to settleAlso what we hear, smell & sense
14 Be aware of overlapping symptoms PAINPAIN KILLERSCONSTIPATIONMANAGE PAINIMPROVED MOBILITYIMPROVED BOWELSIMPROVED NAUSEAMANAGE CONSTIPATIONNAUSEAOUTCOME FOR CLIENT: IMPROVED QUALITY OF LIFE
15 ToolsDo you have any examples of tools you use for assessment?
18 Aims of the session How does ACP fit in with a ‘good death’? What is ACP?An introduction to some of the broader aspectsMental Capacity ActAdvance Decisions to Refuse Treatment (ADRT)Do Not Attempt Resuscitation (DNAR)Yes ok
19 What is a ‘good death’ in relation to a person’s choices and decision making?
20 What is Advance Care Planning? A voluntary process of discussion about future care between an individual and their care providers, irrespective of discipline. If the individual wishes, their family and friends may be included. It is recommended, with the individuals agreement, that this discussion is documented, regularly reviewed, and communicated to key persons involved in their careNHS End of Life Programme 2008
21 Diagram to illustrate Advance Care Planning process Formalises what individuals and theirfamily do wish to happen to themCan be useful to clinicians in planningof individual’s individual careNot legally binding and may also needAdvance DecisionADVANCESTATEMENTADVANCECAREPLANNINGFormalises what individuals do not wishto happen to themLegally binding document, eg (AdvanceDecision to Refuse Treatment (ADRT)and/or DNACPRRelated to capacity of decision making-Mental Capacity ActADVANCEDECISIONS(Gold Standards Framework)
22 What to talk about? Individual’s agenda: What are the individuals feelings about their illness, what concerns do they have, what goals are they looking to reach, do they understand their illness and its prognosis, do they have particular care preferences, now and in the future?Tools that may help trigger conversations:Thinking about it! Prompt cardNotice board postersConversations for life cardsDying Matters Resources/ EventsReminiscence groups/ memory boxes
23 DocumentationThe process of ACP is more important than completing any document………….but it is important to document any ACP outcomes in the most appropriate way and communicate this with appropriate others.
25 Who completes the PPC? Person held document, so... Ideally the individualCould be a relative with individual inputCould be professional/ carer with individualThenKeep it in a visible and easily accessible placeCommunicate the presence of a PPC to others involved in their careTake any necessary actions
26 Recording preferences The explicit recording of individuals/carers wishes can form the basis of care planning in multi-disciplinary teams and other services, minimising inappropriate admissions and interventions.In relation to your health what has been happening to you?What are your preferences and priorities for your future care?Where would you like to be cared for in the future?
27 Supporting Resources: Booklet Provides simple information around:Lasting Power of AttorneyAdvance Decisions to Refuse TreatmentAdvance Care PlansGood way to test the water
28 Supporting Resources: Easy Read Version for use with individuals who have communication difficulties i.e. Learning disabilities, early dementia
29 The PPC is NOT legally binding... However the Mental Capacity Act 2005 dictates that when making a ‘best interest decision’ the decision maker must consider, so far as is reasonably ascertainable—(a) the person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),(b) the beliefs and values that would be likely to influence his decision if he had capacity, and(c) the other factors that he would be likely to consider if he were able to do so.
31 Mental Capacity Act (MCA) 2005 Choice and decision- making by, and on behalf of, people with impaired mental capacity5 Core PrinciplesBest Interest DecisionsIndependent Mental Capacity Advocates (IMCA’s)Advance Decision to Refuse Treatment (ADRT)Appointment of a Lasting Power of Attorney (LPA)
32 5 Core Principles of the MCA A person must be assumed to have capacity unless it is established that they lack capacityA person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without successA person is not to be treated as unable to make a decision merely because of diagnosis or because he makes an unwise decisionAn act done, or decision made under this Act for, or on behalf of a person who lacks capacity must be done or made in his best interestsBefore the act is done, or the decision is made , regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the persons rights and freedom of action
33 Two stage test for capacity Used in order to decide whether an individual has the capacity to make a particular decision:Is there an impairment of, or disturbance in the functioning of a person's mind or brain? if so Is the impairment or disturbance sufficient that the person lacks the capacity to make a particular decision
34 Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) – the local documentation
35 Standardised procedures PatientInformationLeafletLocal DNA(CPR) formInformation for you,your relatives and carers aboutDo Not Attempt CardiopulmonaryResuscitation(DNACPR) DecisionsApril 2013 Version OneHard copywith patient
36 DNACPRUnfortunately, as a complex subject, there is no ‘quick overview’ but there is plenty of guidance available (see resources)Be aware of local policy and local documentationCommunication is keyBe aware of/have systems to document individuals with completed DNACPR documentation
38 Find out more... Advance Decision Making List of resources from ‘Dying Matters’Deciding Right – a northeast initiative for making decisions in advanceDo Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)Decision relating to cardiopulmonary resuscitation – (BMA/Resus Council/RCN)DNACPR decisions: who decides and how? (NeOLCP)