Anticipatory Care Planning

Introduction

Advance care planning (ACP) is about what matters to patients, enabling their wishes to be respected, even when they become unable to engage in decision-making. Evidence shows ACP improves end of life care for patients and reduces relatives' bereavement reactions (Detering KM et al. BMJ. 2010; 340:1345). A simulation course for multidisciplinary healthcare professionals, using actors, was developed to improve understanding of ACP, and confidence in having these conversations. In response to the COVID-19 pandemic, the course was adapted to an online format.

Method

Participants were asked about their ACP confidence and understanding pre- and post-course, using a Likert scale (1-Not at all to 5-Very confident). Data between 2018-2022 was analysed to compare face-to-face and online course responses. Free-text responses to 'How do you feel about attending the course online?' were analysed qualitatively. Ethics approval was not required.

Results

Five face-to-face and five virtual sessions trained 128 and 133 attendees respectively. Confidence in having ACP discussions improved significantly following the course in both cohorts; from a mean Likert rating of 2.77 (95% CI 2.60-2.94, n=132) to 4.11 following face-to-face training (95% CI 3.97-4.25, n=128), and from 2.79 (95% CI 2.66-2.91, n=149) to 4.11 following the online course (95% CI 4.01-4.21, n=133). Additionally, 97% (n=132) of face-to-face attendees and 99.2% (n=133) of virtual attendees said their practice would change because of the course. Following the training, 100% of participants across both cohorts reported that they 'fully understood' what was meant by ACP, from a baseline of 77.3% (n=132) in the face-to-face cohort and 81.9% (n=149) of virtual participants. Free-text analysis highlighted the convenience of attending online (n=22,21%), and only a minority reported technical difficulties (n=8,8%).

Conclusion

This course was successfully adapted to a virtual format, improving participants' ACP confidence and understanding as effectively as in-person training, whilst being more accessible.

Introduction:

Clinical frailty scale (CFS) is used to generate a score ranging from 1 (very fit) to 9 (terminally ill) for people aged ≥65 years. A CFS of ≥7 correlates with a one-year mortality rate of ~50%, making it useful for identifying individuals potentially approaching last year of life. NICE recommend this patient group are offered Advance care planning (ACP). ACP is paramount to ensuring individuals receive high-quality, personalised end of life care. We aimed to investigate CFS documentation and frequency of ACP discussions following educational interventions.  

Methods:

We performed a retrospective analysis of all inpatients admitted to an Elderly Medicine department on a given day. Data for demographics, documented CFS score, and ACP discussions was collected. CFS scores were recalculated to assess accuracy. Following formal education sessions on CFS documentation and ACP delivered to the MDT, data was recollected. Subsequently, CFS scores were recorded within electronic “flowsheets” to ensure scores could automatically populate future clinical notes and be extracted for research purposes. 

Results: 

The initial sample included 61 patients with 52 in the repeat sample. 36% of patients had CFS recorded in the initial sample compared to 77% in the repeat. In the initial sample, there was an 18.1% difference in documented and recalculated CFS for patients with a CFS≥7 compared to 7.7% in the repeat, showing improved identification of advanced frailty. In the initial cohort, 18% had pre-existing ACP and 16.4% had inpatient ACP discussion, compared to 21.2% in the repeat with pre-existing ACP and 15.4% having inpatient ACP discussion; demonstrating minimal difference. 

Conclusions: 

CFS documentation improved highlighting effectiveness of education involving the whole MDT to better identify frailty within the inpatient setting. Despite this, ACP discussion rates remained low. Potential barriers include time-pressure and lack of confidence approaching ACP demonstrating a need for further awareness and training.  

Introduction: Advance care planning (ACP) supports individuals to express their values and goals regarding future care, playing a crucial role in patient-centred approach. The Gold Standard Framework (GSF) recommends offering ACP to those with declining health, functional deterioration, or major health transitions. Prior to this project, Harrogate District Foundation Trust (HDFT) had not evaluated ACP quality for >2 years, relying solely on DNACPR forms and patient notes.  This QIP assessed the impact of implementing the nationally recommended ReSPECT documentation on ACP quality.

Objective:
To evaluate the extent of ACP in frail patients at HDFT and evaluate whether ReSPECT documentation improved these discussions.

Methods:
In cycle 1, a retrospective review of patient notes from June-December 2023 was conducted to assess the depth of ACP, including DNACPR decisions, treatment ceilings, readmission plans and preferences for place of death and care. The Supportive Palliative Indicator Care Tool (SPICT) identified patients suitable for ACP, with those scoring ≥3 (1 point/life-limiting category) classified as most vulnerable. Cycle 2 followed the implementation of ReSPECT documentation in January 2024 and the quality of ACP was reassessed.

Results:
In Cycle 1, only 11% of SPICT-appropriate patients had ACP beyond resuscitation and treatment ceilings, leaving an 89% opportunity for improvement. After ReSPECT implementation, there was an almost 4-fold increase (41%) in more comprehensive ACP.

Conclusion:
The introduction of ReSPECT significantly improved the depth of ACP. However, further improvement is needed. Next steps include implementing a communication skills workshop to enhance healthcare professionals’ confidence in facilitating ACP discussions.

Introduction:

Advance care planning is a process that allows individuals to make decisions about their future healthcare, including end-of-life care, by discussing and documenting their preferences, values, and goals with healthcare providers and loved ones.These are especially critical for patients with serious, life-limiting conditions or for frail older adults who may face unexpected health crises.It is a commonly recognised barrier to care planning however that senior doctors often do not have the time to complete it for all patient’s who require them and that junior doctors lack confidence in having these discussions, this Quality Improvement Project aims at to increase the use of Advance care planning in the form of Emergency health care plan (EHCP) by empowering junior doctors to competently lead these discussions by introducing focused teaching on the topic to regular teaching.

Method:

Our objective was to organize teaching sessions for all junior doctors and LED doctors across University Hospitals of Leicester to educate them identifying suitable candidates and competently leading the discussion. So far we have delivered these sessions during Geriatric departmental teaching, IMT teaching and trust grade teaching and have gathered feedback to assess the teaching. We have also been collecting information on the total number of EHCPs completed by the trust over various periods, following the introduction of focused Advance Care Planning training into regular junior doctor teaching

Result:

After completing the original round of teaching, we found an overall improvement in the confidence that individuals had in both holding conversations about EHCPs and documenting the forms. 63.2% of participants now felt confident in conducting conversations, with 78.9% feeling confident to complete the EHCP form itself in the electronic system. As of now, we have not demonstrated an improvement in the number of EHCPs completed, with an initial result of 39 over the three months before teaching, compared to 36 after teaching. It was also noted that almost all EHCPs were completed in the context of advanced frailty and were not utilized for younger patients with terminal conditions.

Conclusion :

This initiative has been shown to increase junior doctors' confidence in leading ACP discussions, highlighting the need for such training to promote patient-centered care. Expanding this educational effort to include additional training for foundation-level doctors and GP trainees may further enhance advance care planning practices in hospitals. However, it is interesting to note that despite the perceived increase in confidence, the total number of completed plans does not appear to have improved. This may be partly due to our not yet targeting all relevant groups; future rounds of the project should explore the ongoing barriers to completion.

INTRODUCTION

A treatment escalation plan (TEP) should be established for patients at risk of clinical deterioration, particularly when the risks or benefits of specific therapies are uncertain. This plan should be formulated considering inputs from both the patient and their family (SIGN 167). In hospital-at-home setting, TEP was not routinely completed during admission, leading to unclear anticipatory care plans. However, after emphasizing the importance of TEP, we observed significant improvements that positively impacted patient care.

METHODS

Over the course of a month, we collected data focusing on specific TEP-related parameters, without exclusively concentrating on cardiopulmonary resuscitation status (SIGN 167). We highlighted the importance of TEP through ward teachings and integrated its monitoring into our weekly ward round discussions. Additionally, TEP was included in discharge letters.

RESULTS

Initially, our analysis showed that only 7% of patients had TEP completed upon admission, leaving many discharged without clear future treatment plans. A year later, data collection from the same month indicated that 97% of patients had TEP documentation completed on admission, often finalized the same day. This led to clearer care plans for clinical staff, while patients and families gained a better understanding of their preferences in case of deterioration.

CONCLUSION

Standardizing TEP has fostered proactive discussions about ceilings of care for older adults, reducing the need for acute hospital admissions during deterioration and avoiding non-beneficial treatments. By emphasizing timely planning and recognition of acute deterioration, we acknowledge that many patients with life-limiting illnesses prioritize symptom palliation over disease recovery.

Background: This project is based in the geriatric department of Wye Valley NHS trust which serves Herefordshire and mid-Powys.

Introduction : In frail, older patients, cardiopulmonary(CPR) resuscitation has low rates of success. Lack of appropriately completed ReSPECT forms leads to futile attempts of CPR, repeated readmissions and patient harm. This project aims to improve patient centred advance care planning (ACP), and the quality of their documentation in the ‘clinician recommendations’ section in ReSPECT forms through development of new educational tools.

Methods: The Supportive and Palliative Care Indicator Tool (SPICT) was used to identify patients benefitting from ACP in the department. Data was collected on how many patients had ReSPECT forms and how well they were completed against standards adapted from the Resuscitation Council guidelines. Plan-Do-Study-Act(PDSA) cycle 1 was completed developing an aide-memoire (ReSPECT tool), and an interactive workshop. PDSA cycle 2 lead to design of the project poster titled ‘Revamp your ReSPECT discussions’ which was displayed on the wards, and shared on social media. PDSA cycle 3 was conducted to measure response and aid direction. Results: PDSA 1 showed 71% patients meeting SPICT criteria had ReSPECT forms. This improved to 82% by PDSA 3. PDSA cycle 1 revealed that only 32% of ReSPECT forms were completed to audit standards, by PDSA 3 this improved to 43%. The project received engagement from the wider healthcare community on Twitter/X where the project poster garnered over 36,600 views and has been shared in the trusts latest issue of safety bites.

Conclusions: Our work led to an improvement in the quality of documentation and illustrated a novel approach to communicating the standards expected when delivering patient-centred ACP. The interest received via social media highlighted the importance of sharing this experience. We plan on building on this success through wider communication of the standards.

Introduction

In today's healthcare practice, many patients live longer with multiple health issues, often in a frail or terminally ill state. Their quality of life doesn't necessarily improve. These patients require optimal supportive care that respects their dignity. Advanced Care Plans (ACPs) are crucial here, facilitating person-centered discussions about future care preferences while the patients have the mental capacity for meaningful participation. We aim in this study to assess how many patients in General Internal Medicine department would benefit from ACP and compare that to our current practice in implementing ACPs

Method

This cross-sectional retrospective study was done in 2 instances, 1 month apart from 29/03/23 to 01/05/23. The Sample size was 300 patients. The eligibility criteria were life expectancy of 12 months or less, age of 80 years and above, Clinical Frailty Scale (CFS) 8 or more, advanced dementia, and end-stage disease.

Result

33 patients (11%) met the eligibility criteria for ACP. 8 patients (24.2%) were above the age of 85. 25 patients (75.8%) had a Clinical Frailty Scale score higher than 7. 12 patients (36%) had terminal cancer. ACP was done for only 6% of the cases that meet the eligibility criteria. Within three months, 90% of these cases passed away. It is important to mention that in 57.6% of the cases, ACP was discussed with the patient and the next of kin (NOK) but was not formally documented.

Conclusion

Our findings revealed that only 6% of the eligible cases had evidence of ACP. This aligns with the study “advanced care planning in patients referred to the hospital for acute medical care: Results of a National Day of Care survey” which showed 4.8% had an ACP. The absence of ACP in the vast majority of re-admitted patients represents a significant missed opportunity to improve care.

Introduction:

The preference for place of death and the concept of dying in place have been subjects of debate in numerous jurisdictions. Despite the growing prevalence of ageing populations and the increasing demand for dying in place, there is a limited body of literature exploring older adults’ knowledge of dying in place and their preferences for the place of death. In Hong Kong, there are ongoing legislative efforts to revise the policy on dying in place. This study aims to investigate the knowledge of dying in place and the preferences for the place of death among older adults in Hong Kong.

Methods:

This cross-sectional study recruited 503 older adults. A questionnaire was disseminated through online social media platforms and face-to-face interview. ANOVA was conducted to compare the differences in knowledge scores among participants with varying preferences for the place of death.

Results:

Participants demonstrated a sub-optimal knowledge level (mean = 3.55; range 0-8). Notably, 54.7% of participants were unware of the existing law that regulates dying in place in Hong Kong, and 43.5% did not know about the availability of community resources to support patients who choose to die at home. The majority of participants (55.5%) preferred to die at home. Other preferences included hospital (18.9%), hospice (17.1%), and care home (8.5%). Participants who preferred to die at home exhibited a higher knowledge score (mean 3.84) compared to those who preferred to die in hospital (mean = 2.79) (F = 5.323, p = 0.001).

Conclusions:

The findings of this study provide insights that can inform the revision of current policies, the enhancement of community resources supporting dying in place, and the strengthening of life and death education targeted at older adults.

Acknowledgement:

The work described in this paper was fully supported by a fund from Hong Kong Metropolitan University (RD/2022/2.17).

Introduction: NICE guidance recommends that clinical teams should identify patients who are approaching their final year of life. It advises using tools such as the Clinical Frailty Score (CFS) to identify this cohort. Wigan has a significant proportion of severely frail patients would would benefit from this conversation. The aim of this project was to increase the percentage of patients with severe frailty who have an advanced care planning (ACP) conversation during their hospital stay. Method: Retrospective data collected from discharge letters was used to identify patients aged >65 years with a CFS ≥7 Astley ward. Exclusion criteria included patients <65 years old, patients who died during admission, patients who moved wards prior to discharge and re-admissions if within 30 days. The cohort was examined to see if firstly they had been highlighted as a patient who would benefit from ACP, and if an aspect of ACP had been completed during their admission. Results: 10 PDSA cycles were completed over the two years (2021-2023). Our data showed that teaching on ACP and dedicated Registrar sessions on the rota had the greatest impact on improving the completion of ACP discussions. While unified method of CFS assessment on admission and documentation of ACP on shared platforms did not change the ACP uptake significantly. Conclusions: Systematic approach to improving ACP in severe frailty has the potential to improve patient experience and allow them to highlight their wishes at the end of life. Despite trialling multiple activities to increase ACP uptake it was clear whole multidisciplinary team engagement is required to maximise ACP. Therefore, future cycles will examine the impact of implementing a focused approach to ward rounds. Although we have progressed towards our goal, more work needs to be done to maximise uptake of ACP for severely frail patients during hospital admissions.

Background:

Clear and accurate documentation of a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is vital to ensure patients receive appropriate care and autonomy regarding their end-of-life management. Inaccuracies or omissions allow potential for unnecessary or harmful interventions to occur.

Aims/Objectives:

To produce ≥20% improvement in accuracy and overall completion of all sections of respiratory inpatient ReSPECT forms, with particular focus on DNACPR decisions, during a four-month respiratory placement. 

Methods:

Between 21/12/21-29/4/22, DRI inpatient ReSPECT forms were reviewed for completion and accuracy overall and for individual subsections. After two weeks’ pre-intervention data collection, three interventions with complete PDSA cycles (junior presentation, ward posters and emailed consultant presentation) were implemented over 11 data collection points. Interventions reminded doctors to review forms and identify/rectify errors.

Results:

Name documentation showed a 5% sustained improvement. Consultant countersignature completion improved from baseline over seven consecutive data timepoints but wasn’t sustained long-term. No intervention significantly improved overall form completeness and patient preferences remained poorly completed (all ≤30%). 100% documentation of DNACPR status at baseline was sustained throughout. However, discussion details remained poorly documented without significant improvements seen.

Conclusions:

Despite some minor improvements seen, no intervention produced sustained changes to overall completion or key sub-sections. Sample size and project duration are recognized limitations. However, these null results emphasize that current forms are not utilized as intended and that ReSPECT completion could be significantly improved. Findings have contributed to wider research by Palliative and Resuscitation teams.