The Deteriorating Patient: Goals of Care Conversations and Treatment Escalation Planning

1. The Deteriorating Patient: Goals of Care Conversations and Treatment Escalation Planning Steve Bass Lead Clinical Nurse for Palliative & EOLC Phil Rankin, Clinical Fellow

2. What is meant by goals of care?

3. CPR? Quality and / or quantity? What is meant by goals of care? IV Therapy? NIV? MET call? HDU / ICU? ED Re-Attendance? Re-admission? In which circumstances? Keep me at home as far as is possible please Comfort and dignity Person-centred care How I want to live as well as how I want to die What matters to you?

4. Ceilings of Care??? Language matters Is there a limit on care Ceilings of treatment Goals of care What CAN you do for the patient, not what CAN’T we do

5. What we hoped for: • Our acute admissions to be seen, safe and sorted as quickly and effectively as possible: SINGLE CLERKING • To recognise the deteriorating patient and respond in an effective and timely way, supported by useful resources: SPICT, ROCKWOOD, TEP MICRO-GUIDE • To develop robust treatment escalation plans – not just DNACPR: TEP PROMPT CHART • To have a place to document and find these: TEP in SINGLE-CLERKING • To ensure our response to their deterioration is communicated within and outside of the hospital: ReSPECT, IBIS, PANDA

6. Overall Goal #GOC #TEP All patients at BSUH have a clear Goal of Care and Treatment Escalation Plan aligned to the ReSPECT Process Normalising conversations about goals of care, thinking about the future, death and dying and the quality and nature of life lived in between Supporting shared decision making, involving all relevant people

7. Thank you for your support What’s the evidence that we need to consider deterioration and have essential conversations from the start? Reforming the front door: single clerking acutefloorproject@bsuh.nhs.uk

8. When can we make a difference to the deteriorating patient? Many opportunities…however MET calls mostly happen out of hours and within 72 hours of arrival 91% of all calls were for patients within 72 hours of admission 80 % of MET calls are in the first 48 hours of patient admission. 74% all MET calls were out of hours

9. I’ll do it later or next time… • Escalation plans after a MET call showed a reduction in the number of patients for full escalation. • Perhaps some could have had escalation plans communicated at admission/previous admission rather than after a medical emergency? • 48% had no plan pre MET call • 33% had no plan post MET call • 83% patients had received an ST3+ review in the 48 hours prior to the MET call - opportunity

10. BSUH: Hospital admissions in last 12 months,for those patients who died in 2018 [n= 1662]

11. 1 in 3 = last year of life1 in 10 of these = likely to die during admission Planning for the future is everyone’s business – as is frailty, dying and chronic illness ½ all people die in hospital, most don’t want to. Better planning may prevent this.

12. 80 year old woman 76 year old man

13. Early focus on TEP and overall goal of care to support less of this • “Let’s continue with IVABx for a further 48Hours” • ‘ Lets give two sensible shocks’ • Do I just send her home with some Oramorph and a prayer?

14. Perceptions and Realities RCP 2018: “evidence from patients and carersindicates that many people wanted to talk about death and that planning helped them feel more empowered about their care and decision making” “Starting those difficult conversations about end of life needs and wants is challenging work for family members and for professionals” BMJ: “Many families have regrets after the patient has died that such opportunities for hearing the patient’s wishes and for making choices and preparations were missed and that professionals had not told them that death could happen soon.”

15. Early focus on TEP and overall goal of care to support less of this

16. What can stop us having these conversations? • RCP Oct 2018 Report – an excellent read…

17. Whose job is it to have these conversations? If they don’t think it’s their job what do we do?

18. How does it make you feel when you are on call at 3AM with a frail deteriorating patient whose GOC and TEP have not been discussed or documented?

19. Early focus on TEP and overall goal of care to support more of this Discussing and documenting TEP and goals of care to become routinepart of admission Embedded in clerking and senior review process

20. SPICT App Frailty – Rockwood Score Capacity “Could this patient be in the last year of life?” Prompts supporting early recognition Delirium and Dementia “Does this patient have an existing TEP / DNACPR / ReSPECT / ADRT”

21. “What is the Goal of Care?”Prompt Chart Supporting Robust TEP

22. ABCDon’t Ever ForgetGoals of Treatment and Care They are, or may deteriorate but: Pause… Think… What are their goals of treatment and care? What is their Treatment Escalation Plan (TEP) It’s not just ABCDE… Airway Breathing Circulation Disability / Drugs ExposureConsider F+G… Frailty and Fitness Goals of Treatment and Care #HaveTheConversation (and document it) A. FULL ACTIVE TREATMENT ? B. REQUIRES FURTHER TREATMENT DECISIONS ?

23. Previous TEP at BSUH

24. Thank you for your support Reforming the front door: single clerking acutefloorproject@bsuh.nhs.uk How can we contribute to conversations about goals of care and treatment escalation planning from admission?

25. Integrated TEP in single clerking process – Page 12 Placing and supporting a TEPwhere all can see, at a time a patient sees an senior decision maker Role when clerking / post-take prompting and beginning completing these / collating of relevant info Patient advocateduring senior review

26. TEP / GOC Prompt – Page 2

27. Thinking about need for TEP GOC issues to feature in your initial problem list Shapes mindset and care and treatment plans of teams who see the patient after you

28. Many forms, one process

29. ReSPECT

30. ReSPECT is coming!Patients may start to attend with it KSS collaboration

31. Another issue - overwhelming + Hard to find the information

32. Microguide: New Deteriorating Patient Section in Cross Specialty Guide

33. Taking it Further • Structured Judgement Reviews (SJR) • Email ollie.minton@nhs.net if interested • Cycle of learning from SJR confidence and competence  improved TEPs • SJR template now on Panda • Audit and QI • Single clerking TEP audit, rolling EOLC audit, MET audit, join deteriorating patient steering group • Education • Local, regional, national opportunities + sim

34. Taking it FurtherFinally connecting up patient information including GOC / TEP data across KSS • Panda – internally and externally visible • IBIS (SECAMB) • Systm1 (Primary Care) • KSS overall plan

35. Take Home • Role to play in TEP/ GOC and are role models • You have the experience and authority to advocate for these patients • Recognise frailty/risk deterioration early – prompts • Promoting GOC and TEP conversations and normalise them • Bigger picture – actions / efforts now may prevent reattendance in the future / better patient experience

36. “Doris” • 86 year old female, brought to A+E via ambulance • PC: Fall • HPC: • Fell at rehab nursing home while on toilet • Slightly lightheaded before falling • No chest pain or palpitations • Worsening breathlessness and cough for last 3 days • Wheezy

37. “Doris” • PMH: • COPD • Vascular Dementia [Unclear] • IHD and heart failure • OA • HTN • SH: In nursing home, requiring assistance with activities of daily living and personal care. Mobilises with zimmerframe. Family live nearby.

38. “Doris” • 3 admissions in last 6 months • IECOPD • Fall • CAP • Discharged to rehab nursing home last time • Prior to this, had increasing POC each time she was discharged from hospital

39. Clinical Observations: RR 25, Sats93% on 28% O2 via Venturimask. Sounds Wheezy HR 120bpm. BP 94/60, T 37.8 Doris appears slightly confused, but alert NOK = niece NEWS2 = ? No Treatment Escalation Plan or Goals of Care from this or previous admissions documented.

40. Small group work • You are the full clerking doctor who will be looking after Doris for the rest of the day. Niece thinks Doris would want whatever doctors think best. • In groups: • Evaluate Doris’ frailty, risk of unmet supportive and palliative care needs and risk of deterioration • Write an initial plan which includes information a senior reviewer might need to make decisions about Doris’ TEP • Senior reviewers – what information is most helpful to you to make these decisions?

41. Small group work • Senior reviewers • Using the information collated by the clerking doctors and your own views - please complete the treatment escalation plan for Doris

42. Small group work • Tell us about your experiences • What would you change if you could?

43. “Doris” • Doris continues to deteriorate • You are concerned she may now be dying • What should you do?