Advance /Anticipatory Care Planning (ACP)

OCTOBER 2010

Sandra CampbellConsultant Nurse

- Cancer and Palliative CareChair Sub group of SLWG3 on Advance Care

Planning

Sandra.campbell2@nhs.net

Advance Care Planning Department of Health (2006)

‘a process of discussion between an individual and their care providers irrespective of discipline’.

Working group definition (2010)Advance care planning as a philosophy, promotes discussion in which individuals, their care providers and often those close to them, make decisions with respect to their future health or personal and practical aspects of care.

These discussions should result in a documented record of what the individual does/does not wish to

happen.

Advance care planning

Planning for end of life care can be done at any stage of life from well to dying but usually through facilitated conversations that will incorporate patient and carer choices.

Anticipatory care planning

Planning for situations including a change in health status we expect or anticipate may happen to patients with chronic conditions throughout the illness trajectory.

The outcome of both may be documented in an Anticipatory Care Plan

Why the need for two terms?

Along life’s journey, we do not just develop a chronic condition, become unwell and then die, we will often have to face a very winding road with death perhaps expected on more than one occasion with difficult conversations and decisions required.

ABCD of Dignity Conserving care ABCD of Dignity Conserving care (Chochinov, 2007) (Chochinov, 2007)

AA -- AttitudeAttitudeBB -- BehaviourBehaviourCC -- CompassionCompassionDD -- DialogueDialogue

ACP Toolkit (examples follow)www.scotland.gov.uk/livinganddyingwell

Umbrella for ACP Conceptual Framework ABCD practical guidance for Thinking Ahead Definitions Sample ACP plans and documents Core components Triggers for ACP SBAR and a range of other supporting

documents FAQ’s Reference List

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Advance Statement

Self Management Plan (with professional)

)professional)

Thinking Ahead/ Statement of Wishes

Anticipatory Care Plan (ACP)

Advance Decision

Liverpool Care Pathway

AAnn AAnnttiicciippaattoorryy CCaarree PPllaann mmaayy ccoommpprriissee aannyy oorr aallll ooff tthheessee.. Their completion will inform the Electronic Palliative Care Summary

Welfare Guardian

Welfare Power of Attorney

Electronic Palliative Care Summary/

OOH Handover form

A Conceptual Framework of Advance Care Planning – A Continuum of Opportunities

Well person Culture of open discussion about death, dying and spiritual needs. Dying person

Possible health/social triggers /Consider GSF / Prognostic Indicators eg PPSv2/ Assessment tools

Health and social care professionals, Primary care team, Acute care team Working

Reduction in risk of complicated grief

Change in health status

Chronic condition

Sudden illness

Life-limiting diagnosis

Terminal diagnosis

Last few days

Making a will Getting financial advice Power of attorney Social work involvement Bereavement

Solicitors, Social Workers , Voluntary agencies

Marriage or civil partnership Buying a house Getting a mortgage Getting insurance Education, Faith groups Cultural groups

Advance Directive or Advance Decision Statement of wishes Thinking Ahead

Completion of Anticipatory care plan / Electronic palliative care summary / out of hours handover form/ LCP

ABCD of Thinking Ahead

A = ACP B = Begin C = Communicate and Co-ordinate D = Delivery

Advance and Anticipatory Care Planning, in practical terms are both about adopting a “thinking ahead” philosophy of care.

Change in health status

Recognition of likely life-limiting change in condition and/or living alone

Onset of a sudden illness

Diagnosis of chronic progressive incurable condition

Death expected in the next few days

Liverpool care pathway (LCP)

Anticipatory care plan

Thinking ahead

Statement of wishes

Advance decision / Advance directive

Electronic palliative care summary

Out of hours handover

Possible Outcomes of Anticipatory / Advance Care Planning

Possible triggers

Change in carer circumstances

Changes in home circumstances

The triggers and the outcomes are not necessarily sequential and the processes to be implemented should always be the result of considered clinical judgement and include discussion with the patient/carers

By adopting an advance care planning philosophy, the right care will be given at the right time by the right person with the right

outcome to the right quality standard.

Possible triggers for implementing the philosophy of Advance Care Planning

SBAR communication tool

S: Situation B: Background A: Assessment R: Recommendation

Haig et al (2006)

Support for ACP

The development and implementation of ACP had been supported by a wide range of national and local policies and guidelines.

There is also a growing body of academic literature in support of ACP however this does need to be evidenced by robust research.

Potential benefits of ACP

Patients receive the care they desire Appropriate management Support for decision making Reducing the risk of complicated grief

Summary of RecommendationsSummary of Recommendations

1.1. Advance care planning needs to be accepted as an Advance care planning needs to be accepted as an overall concept covering an umbrella of terms and overall concept covering an umbrella of terms and processes including anticipatory care planning for processes including anticipatory care planning for patients with Long Term Conditionspatients with Long Term Conditions

2.2. Agreed definitions essentialAgreed definitions essential

3.3. Engagement with whole population necessaryEngagement with whole population necessary

4.4. Core components need to be contained within any Core components need to be contained within any documentdocument

5.5. Coordinated education critical to implementation Coordinated education critical to implementation

6.6. Suggested use of tools such as SBAR communication tool Suggested use of tools such as SBAR communication tool and electronic palliative care summary to support and electronic palliative care summary to support communication between teamscommunication between teams

Recommendations contd.Recommendations contd.

7.7. Formal audit and evaluation of any Formal audit and evaluation of any documentation, following death to assess documentation, following death to assess outcome of ACPoutcome of ACP

8.8. ACP discussions should contain components as ACP discussions should contain components as recommended by DOH (2007) and DNACPR and recommended by DOH (2007) and DNACPR and organ donation as appropriateorgan donation as appropriate

9.9. ACP should be considered on admission to ACP should be considered on admission to Nursing/Care Home Nursing/Care Home

10.10. In applying ACP, there may be 3 types of In applying ACP, there may be 3 types of documentation, Legal, Personal and Clinical documentation, Legal, Personal and Clinical

11.11. Local arrangements should be in place to ensure Local arrangements should be in place to ensure an updated copy of the anticipatory care plan is an updated copy of the anticipatory care plan is with the patient/carerwith the patient/carer

An Advance/Anticipatory Care Planning philosophy is An Advance/Anticipatory Care Planning philosophy is advocated advocated

A coordinated approach to education is requiredA coordinated approach to education is required A collaborative approach with improved A collaborative approach with improved

communication with patients/carers and between communication with patients/carers and between teams is crucialteams is crucial

The transition from The transition from livingliving with a chronic condition to with a chronic condition to dyingdying will be as seamless as possible will be as seamless as possible

The vision is for equitable care for patients with long The vision is for equitable care for patients with long term conditions and those at the end of life to term conditions and those at the end of life to facilitate the right thing being done at the right time facilitate the right thing being done at the right time by the right person, to the right quality standard by the right person, to the right quality standard with the right outcome!with the right outcome!

In ConclusionIn Conclusion