Step 2 workshop

What does holistic mean to you?

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

Holistic assessment Is a continuous process & leads to: More effective care and treatment of symptoms More client-centred (client’s priority) Improves communication between all professionals involved with care Improves evaluation of treatments Reassures/includes client’s family Improves the client’s quality of life

The whole person? PHYSICAL PSYCHOLOGICAL SPIRITUAL SOCIAL

An example is ‘total pain’ Emotional & Psychological Physical ‘TOTAL PAIN’ Social Personal & Spiritual

Group Work

Case study Eloise 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: Physical Psychological Spiritual Social

Assess, plan, implement, evaluate

Help with assessments What questions should you ask?

Ask…. Nature – what is it like Location – where do you get it Severity – what is it like at its worst Frequency – how often do you get this Duration – how long does it last Triggers – does anything bring it on/ make it worse Alleviating factors – does anything relieve it Assessment tools useful e.g. body charts, symptom diaries.

Observing behaviour Sweating Loss of appetite/fluid intake Guarding Urinary & faecal incontinence Sleep disturbance Increased confusion Facial expression Assuming a foetal position Agitation Increased/decreased movement withdrawal Hard to settle Also what we hear, smell & sense

Be aware of overlapping symptoms PAIN PAIN KILLERS CONSTIPATION MANAGE PAIN IMPROVED MOBILITY IMPROVED BOWELS IMPROVED NAUSEA MANAGE CONSTIPATION NAUSEA OUTCOME FOR CLIENT: IMPROVED QUALITY OF LIFE

Tools Do you have any examples of tools you use for assessment?

Assessment Tools Skin Breakdown – Braden/Waterlow Oral Assessment HOPE - Spiritual assessment Pain Fluids Bowels

Advance Care Planning

Aims of the session How does ACP fit in with a ‘good death’? What is ACP? An introduction to some of the broader aspects Mental Capacity Act Advance Decisions to Refuse Treatment (ADRT) Do Not Attempt Resuscitation (DNAR) Yes ok

What is a ‘good death’ in relation to a person’s choices and decision making?

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 care NHS End of Life Programme 2008

Diagram to illustrate Advance Care Planning process Formalises what individuals and their family do wish to happen to them Can be useful to clinicians in planning of individual’s individual care Not legally binding and may also need Advance Decision ADVANCE STATEMENT ADVANCE CARE PLANNING Formalises what individuals do not wish to happen to them Legally binding document, eg (Advance Decision to Refuse Treatment (ADRT) and/or DNACPR Related to capacity of decision making- Mental Capacity Act ADVANCE DECISIONS (Gold Standards Framework)

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 card Notice board posters Conversations for life cards Dying Matters Resources/ Events Reminiscence groups/ memory boxes

Documentation The 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.

Preferred Priorities for Care (PPC)

Who completes the PPC? Person held document, so... Ideally the individual Could be a relative with individual input Could be professional/ carer with individual Then Keep it in a visible and easily accessible place Communicate the presence of a PPC to others involved in their care Take any necessary actions

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?

Supporting Resources: Booklet Provides simple information around: Lasting Power of Attorney Advance Decisions to Refuse Treatment Advance Care Plans Good way to test the water http://www.endoflifecareforadults.nhs.uk/publications/planningforyourfuturecare

Supporting Resources: Easy Read Version for use with individuals who have communication difficulties i.e. Learning disabilities, early dementia http://www.endoflifecareforadults.nhs.uk/publications/preferred-priorities-for-care-document-easy-read-version

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.

Let’s go back to Eloise (i)

Mental Capacity Act (MCA) 2005 Choice and decision- making by, and on behalf of, people with impaired mental capacity 5 Core Principles Best Interest Decisions Independent Mental Capacity Advocates (IMCA’s) Advance Decision to Refuse Treatment (ADRT) Appointment of a Lasting Power of Attorney (LPA)

5 Core Principles of the MCA A person must be assumed to have capacity unless it is established that they lack capacity A 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 success A person is not to be treated as unable to make a decision merely because of diagnosis or because he makes an unwise decision An 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 interests Before 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

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

Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) – the local documentation

Standardised procedures Patient Information Leaflet Local DNA(CPR) form Information for you, your relatives and carers about Do Not Attempt Cardiopulmonary Resuscitation(DNACPR) Decisions   April 2013 Version One Hard copy with patient

DNACPR Unfortunately, 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 documentation Communication is key Be aware of/have systems to document individuals with completed DNACPR documentation

Eloise (ii)

Find out more... Advance Decision Making List of resources from ‘Dying Matters’ http://www.dyingmatters.org/page/advice-professionals Deciding Right – a northeast initiative for making decisions in advance http://www.theclinicalnetwork.org/end-of-life-care---the-clinical-network/decidingright Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) Decision relating to cardiopulmonary resuscitation – (BMA/Resus Council/RCN) http://www.resus.org.uk/pages/dnar.pdf DNACPR decisions: who decides and how? (NeOLCP) http://www.endoflifecare.nhs.uk/search-resources/dnacpr-web-resource.aspx