Chair: Kitty Vivekananda
a. Health professionals’ experiences of providing advance care planning in the context of clinical deterioration: A qualitative study
Ms Wendy Pearse (presenting), Dr Maureen O'Neill, Prof Mervyn Hyde, Assoc Prof Florin Oprescu
Background Approximately one-third of Rapid Response Team reviews in hospital in response to clinical deterioration involve a patient who is approaching the end-of-life. Patients’ health status can deteriorate suddenly with little time to discuss goals and/or ceilings of care as part of an Advance Care Planning (ACP) process. It is not appropriate for the RRT to provide ACP as a clinical service, however this event could be the catalyst to do so. It is not well understood whether this occurs, and the dearth of research about the role and experience of multidisciplinary teams in providing ACP highlights a current gap in the literature. Aims This study examines the experiences and beliefs about perceived triggers, facilitators and barriers, roles and responsibilities of the range of health professionals providing ACP as a clinical service following the clinical deterioration of hospital inpatients. Design Fourteen health professionals from medical, allied health and nursing groups participated in an individual, in-depth, semi-structured interview. Interviews were digitally recorded, transcribed verbatim, and transcripts entered into NVIVO. Line-by-line coding was conducted and a detailed thematic analysis undertaken to analyse the data using an inductive approach. Results Many participants were knowledgeable about some, or all key elements of ACP. Participants identified clinical deterioration as a prompt for ACP provision, without necessarily completing formal documents. A team-based approach valuing the diverse skills and experience of health professionals was supported. Medical staff considered the overall responsibility for decision-making to lie with them, with allied health and nursing staff having key roles in working through ACP processes such as documentation. Conclusions This study identified implications for practice, including how clinical deterioration may trigger ACP provision, and readiness for a broader range of health professionals to provide ACP. This will require support through effective continuing professional development, policy that considers generalist and specialist roles for ACP provision, and consideration of potential impact on professional groups by professional organisations.
b. Using Talking Mats, a visual communication framework, to support people to think and plan ahead for the end of life
Dr Joan Murphy, Co Director, Talking Mats Ltd
Lois Cameron, Co-Director, Talking Mats Ltd
Dr Sally Boa, Head of Education & Research, Strathcarron Hospice
Mrs Susan High, Community Development Lead, Strathcarron Hospice
(presenting) Mrs Marjory Mackay, Director of Nursing, Strathcarron Hospice
Using Talking Mats, a visual communication framework, to support people to think and plan ahead for the end of life
We conducted a community project, ‘living right up to the end’, which aimed to find out what people living with long term conditions want and need to support them to make plans for the future. People told us they found it difficult to talk to family about making plans and preparing for death.
We aimed to develop a tool to support people living with deteriorating health to have conversations about making plans for the future.
We worked in partnership with an international Social Enterprise (Talking Mats), who have developed a visual communication framework that supports people to express their views. We worked with Hospice staff to develop topics and options relevant to planning ahead (Affairs; Care/treatment and Personal values). These were then tried out by a range of people living with long term conditions in our local community.
Use of the Talking Mats ‘thinking ahead’ resource helped people to reflect on their preferences relating to care and treatment and discuss these with their families and the health and social care team. The symbols also enabled them to identify what plans they had made and helped them realise what they still needed to do. They were then able to develop actions plans relating to planning ahead.
Conclusion and Application to PHPC:
Staff and volunteers found training on the resource essential to help them use it effectively. It provided them with a tool to support people to broach a difficult subject. Talking Mats can be used by staff and compassionate neighbours in any setting to support people to express their views and help them plan for the end of life.
c. Reflecting on life: How can we ask the right questions with faced with death?
Background Community geriatric medicine allows specialists to work closely with Residential Aged Care Facility (RACF) staff, General Practitioners (GPs), residents and families. Patients in RACFs frequently have life-limiting (terminal) diseases such as dementia and frailty. Furthermore, they may have expressed through their lives that they never wished to be in a RACF. Through a combination of medical intervention and circumstances, patients may have become RACF residents and lost control of the present and future they wanted.
Aims Through a case exploration, reflections will be offered on key moments where Advanced Care Planning (ACP) could have occurred. The aim is to help participants consider what they could change in their own spheres of influence. Actions A 92-year-old has been a RACF resident for one year. The previous year she was treated for cancer which markedly worsened her function, thinking and quality of life. She had previously expressed that she never wanted to go to a nursing home and in recent years said she was ready to die. A recent stroke has left her fully dependent on all instrumental activities of daily living.
Outcomes Upon reviewing this lady, many viewpoints were considered from the resident’s family’s perspective, the GP and the RACF staff. It was agreed that the lady was coming to the end of her life, so palliative care was initiated with a focus on providing comfort for her remaining days. The family asked why this could not have happened two years ago and were happy for her now but sad that she had two years of ‘misery’.
Conclusions There are key moments in someone’s life where recognising the balance of benefit vs harm in medical care may change. Reflecting on this case and anchoring with participants’ experiences help to identify how we can take-home strategies to change our local cultures.
d. End of life care issues for people diagnosed with a mental illness
(presenting) Ms Helen Butler, University of Auckland
Mr Tony O'Brien, University of Auckland
End of Life Care Issues for People Diagnosed with Mental Illness (MI)
Background - When working in mental health I noticed that people diagnosed with Mental Illness (MI) were often living with and dying from their physical co-morbidities. Whilst working in specialist palliative care I observed the small number of patients referred to or within our service who had MI diagnoses.
Aims/Purpose – For my masters’ project I undertook a literature review and retrospective cohort study which identified the rates of access to specialist palliative care for people diagnosed with MI compared to the general population.
Results/Finding – The findings of current literature (including NZ and Australian studies) show increased morbidity and mortality risk for people diagnosed with MI. There is a need for access to a palliative care approach for people with MI who are also diagnosed with life limiting physical illness. The results of my research identified that people diagnosed with MI who died of physical co-morbidities were less likely to access specialist palliative care services.
Conclusions and Application to PPHC – I will identify how this study links to the wider issues of palliative care access and provision for people who experience MI. I will contextualise my findings within our current health system and provision of palliative services including who is best placed to be providing palliative care and supporting people who are diagnosed with MI and who are dying.