1. How to Open Discussions and Plan care for End of life with Patients, their Friends and Families Dr Natasha Arnold Consultant Geriatrician

2. Aims of presentation Case finding/ Indentification using SPICT( Supportive and Palliative care Indicator Tools ) Case examples of common conditions & approach to EOLC discussions Advice on Drugs Complex patients/ seeking advice advice Legal issues to consider

3. SPICT non-specific indicators Look for >2 clinical indicators of deteriorating health: 1. Performance status poor or deteriorating (needs help with personal care, in bed or chair for 50% or more of the day). 2. Two or more unplanned hospital admissions in the past 6/12. 3. Weight loss (5 - 10%) over the past 3 - 6 months and/or body mass index < 20. 4. Persistent, troublesome symptoms despite optimal treatment of any underlying condition(s). 5. At risk of dying from a sudden, acute deterioration ( reflect on history). 6. Lives in a nursing care home or NHS continuing care unit, or needs care to remain at home. 7. Patient requests supportive care and needs palliative care as result of treatment withdrawal.

4. SPICT specific indicators Advanced Cancer Advanced CVS, RS, CKD and liver disease. Advanced Neurological disease Advanced Dementia/ Frailty-less good as too subjective and open to interpretation.

5. Case of 78 year old house bound lady HT 25 years, Type II DM 15 years on Insulin IHD with 2x MI and CABG 5 years ago with complicated recovery now advanced CCF/LVF with SOB at rest CKD stage 4/5 -3x admissions last 6/12 AKI Registered blind and housebound since 2010 with PoC Tds sith supervised transfers, with x1 bed/chair/commode How would you start discussions?

6. How would I start these conversations Patient Reflection of health/ ill health and admissions recently Patient interpretation of where their health is going in the future What issues they have found makes living harder or easier at home or in hospital Have they had thoughts about dying and what they fear or would like to happen around their own death?

7. Case of 84 yr man house bound in nursing home Lewy body dementia for 2 years Bed bound with catheter Hoisted and risk fed up right with soft moist diet. 3x admissions with delerium due to aspiration pneumonia, AKI and UTI in last year Daughter visits every1/12 and she wants him escalated to hospital for any deterioration. She has been asking staff about invasive feeding

8. Is there a right way to open these discussions? these discussions? How perhaps not to do it?

9. Symptom prevalence in advanced disease (Solano, Gomes & Higginson, Journal Pain & Symptom management. Jan 06) Cancer Pain35-96% Confusion6-93% Anorexia30-92% Fatigue32-90% Anxiety/depression 3-79% Dyspnoea10-70% Insomnia9-69% Nausea6-68% Cardiac failure Dyspnoea60-88% Fatigue69-82% Pain41-77% Anxiety/depression 9-49% Insomnia36-48% Nausea17-48% Constipation38-42% Anorexia21-41%

10. Drug review priorities Refer to Tower Hamlets drug review in LYOL advice in pack Broadly think of stopping in sequence: –Primary prevention drugs –Secondary prevention drugs where the morbidity related LTC is already at end stage –LTC treatment drugs- review symptoms and cut those out that exacerbate or cause additional symptoms and negotiate around those that still have a role in managing the LTC.

11. EOLC discussions to ACPs Indentification with SPICT Complex ? Role of Geriatrician Role of One Hackney MDT Palliative care team and St Josephs CMC

12. How CMC can assist care providers: 12 Reduction in number of unnecessary hospital admissions Reduction in the cost of hospital stay Reduction in length of stay in hospital Increases the number of patients with an advance care plan Preferred place of care and dying achieved Integrated service provision from all primary care sources

13. When do you consider DNAR decisions? And when should you? What do you do when you have considered?

14. What is the difference between Advanced Care plans and Advanced Directives? Consider in context of PPC, One Hackney ACP vs CMC ACP and escalation plans vs ceilings of care

15. DEFINITION OF AN ‘ADVANCE DECISION’ “Advance decision” is a documented decision made by an adult with capacity that if: (a) at a later time a specified treatment is proposed to be carried out by a person providing health care, and (b) at that time he lacks capacity to consent to that treatment, That specified treatment is not to be carried out or continued.

16. When Advanced decisions are not binding   Person lacked capacity to make it   Person still has capacity, so can take own decision   Person changed their mind when they still had capacity   It is not the treatment specified   It is not the circumstances specified   Person may not have made it had they anticipated the current circumstances

17. Lasting Power of Attorney  A lasting power of attorney is a power of attorney under which the donor ‘P’ confers on a donee or donees authority to make decisions about all or any of the following:  P’s health and welfare or specified matters concerning P's personal welfare  P’s property and affairs or specified matters concerning P's property and affairs,  An LPA includes authority to make decisions in circumstances where P no longer has capacity. LPA Personal Welfare Property Affairs

18. http://www.legislation.gov.uk/ukpga/2005/9/contents National Council for Palliative Care ‘Advance Decisions to Refuse Treatment – a guide for health & social care professionals’ BMJ Oct 2013 A.Mullick, J Martin ‘An introduction to advance care planning in Practice’.

19. What do you want to know about identifying and managing those approaching end of life?