1. Step 2 workshop

2. What does holistic mean to you?

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 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

5. The whole person?
PHYSICAL
PSYCHOLOGICAL
SPIRITUAL
SOCIAL

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

7. Group Work

8. 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

9. Assess, plan, implement, evaluate

11. Help with assessments
What questions should you ask?

12. 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.

13. 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

14. 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

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

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

17. Advance Care Planning

18. 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

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 care
NHS End of Life Programme 2008

21. 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)

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

23. 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.

24. Preferred Priorities for Care (PPC)

25. 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

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 Attorney
Advance Decisions to Refuse Treatment
Advance Care Plans
Good 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.

30. Let’s go back to Eloise (i)

31. 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)

32. 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

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
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

36. 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

37. Eloise (ii)

38. Find out more... Advance Decision Making
List of resources from ‘Dying Matters’
Deciding Right – a northeast initiative for making decisions in advance
Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)
Decision relating to cardiopulmonary resuscitation – (BMA/Resus Council/RCN)
DNACPR decisions: who decides and how? (NeOLCP)