CLEARx decisions

Consultant Leadership in EOLC ACP and Rx

decisions

Acknowledgements

• Executive sponsor: Brendan Murphy

– Exec. assistance: Lucy Evans

• Clinical leads: Daryl Jones, Juli Moran, Simon Judkins

• Steering committee: Adele Burgess, Andrew Hardidge,

Paul Gow, Doug Johnson, Liz Jones, Andrew Nunn,

Stephen Warrillow, Karen Detering

Friday 12TH Sep 1pm – 8:30 pm

1. 61 yo, metastatic Ca, 3rd line chemo, ↓ BP / ↑ O2.

2. 88 yo MND, IHD, Cr 140, AMI and intra-abdominal sepsis for ?

procedure.

3. 74 yo c’myopathy, 3rd MET low BP after elective surgery.

4. 87 yo multiple co-morbidities. Elective procedure. Unexpected

bleeding + unplanned post-op ventilation.

5. 77 yo Ca of UO, pall chemo, low BP, SOB, 2 METs.

6. 51 yo EF 21%, DM, infected toes recent d/w friend, VF arrest,

ICU.

Many decisions Un-CLEARx

SMS leadership EOLC

• Commenced Aug 2013

• First SMS EOLC forum March 2014

• Presented to hospital executive April 2014

• "CLEARx decisions"

– Advancing Austin: Exec. Sponsor, Board approved

– Junior palliative care consultant

– Steering committee

Aims and objectives

• To make ACP and EOLC part of daily / routine care

– So that not a “surprise” when a patient deteriorates

» “De-escalation” of care

– Clear decisions, communication, and documentation

» Patients / families

» Stds 2, 9

– Only offer / provide care which is beneficial

• Local leaders

– Implement locally appropriate strategies

• To improve referrals

– Respecting Patient Choices (advance care planning)

– Palliative care consult registrar

• Train senior doctors in the recognition, communication skills and treatment related to the dying patient

CLEARx decisions – progress since April

• Targeted projects

– Cardiology = heart failure

– Gastro = chronic liver disease

• Encouragement of other projects (eg aged care, gen med, oncology)

• List of educational resources for dissemination

• Discharge summary field on EOLC in Cerner

• List of 50 – 100 SMS engaged in ACP / EOLC (43 so far)

• SMS communication workshop 29th Oct (36 yes, 12 maybe)

• Registrar communication workshop 21st October

– SMS asked to nominate and encourage registrars to attend

Gastroenterology project

• Aims to improve recognition of patients with chronic liver

disease who may be approaching the end of life

• To ensure that these patients have clearly identified and

documented goals of care, to facilitate appropriate

management throughout trajectory of illness

• Baseline audit of documentation, follow up after implementation

of education strategy and new section on discharge summary

• Improve opportunities for formal advance care planning through

training of in-house RPC facilitator (liver nurse)

• Guidelines for management of CLD in community

Gastro audit results (n = 20)

• Inpatient notes

– Resus plans: 35%

– Guardian/MEPOA paperwork: 10%

– ACP paperwork: 5%

– Discussion re GOC w pt/family: 30%

• Rest of file Diagnosis Intent of Rx Pt’s GOC

D/C summ 95% 40% 5%

Clinic notes 84% 10% 2%

Clinic letters 93% 21% 6%

MDM notes 65% 31% 0%

Cardiology project

• Aims to improve recognition of patients with irreversible

heart disease who may be approaching the end of life

• To ensure that patients have clearly identified and

documented goals of care, to facilitate appropriate

management throughout trajectory of illness

– Avoiding both defragmentation of care and burdensome

therapies

• Amongst other efforts: audit of documentation, pre and

post rollout of new section on discharge summary

– Cardiology reg (gen med trainee) applying for ethics approval

New section on discharge summary

• "Advance care planning"

• Originally "End of life care issues"; mooted by working party

• Prompt - "Complete for patients with advance care planning"

• Will change to "Complete for patients with life-limiting illness"

• 2 parts, both free text

• "Goals of care" - intended to capture medical & patient goals

• "End of life discussions"

• Guidance for HMOs and SMS, with suggested formats

Educational resources

CareSearch (caresearch.com.au)

Many topics.

Many links to other resources.

Pre-existing Pubmed searches to allow up-to-date literature reviews, including grey literature.

Consumer pages/resources, including for carers.

Symptom management

Therapeutic Guidelines – Palliative Care, 3rd Ed. Also available via Hub/Toolbox/Clinicians Health Channel.

CareSearch has many resources re symptom management (link is to symptom mx page).

PCF4 – more specialised text book (available electronically and in hard copy at palliativedrugs.com) with drug

monographs and symptom management guidelines.

Cerner Caresets

These aim to facilitate prescription of appropriate symptom management. They are a starting point only and need to be tailored to the individual patient.

Palliative Care Meds – search for “palliative” when ordering a new medication.

Care of the Dying Meds – search for “care” when ordering a new medication.

Catastrophic Terminal Events – search for “catastrophic” when ordering a new medication.

Educational resources (cont.)

Hospital guidelines

Care of the dying

Nausea & vomiting in palliative care

Terminal respiratory secretions

Hospital supply of medications to palliative care patients in the community

Catastrophic terminal events

Palliative care patients discharged home with a continuous subcutaneous infusion

Religious guidelines for the care of the dying

Care of the deceased

Advance care planning

Family meeting guidelines for cancer services

Terminal restlessness (not quite live)

Educational resources (cont.)

Advance care planning

Advance Care Planning Australia website – formerly Respecting Patient Choices website, includes resources for

professionals and consumers.

Department of Health website – new Advance Care Planning Strategy launched this year.

Decision Assist website – new 24/7 national Palliative Care Phone Advisory Service, now available to assist GPs

and health professionals working with older Australians.

Prognostication

CareSearch page

Gold Standards Framework Prognostic Indicator Guidance – UK resource, for malignant and various non-malignant conditions.

Supportive and Palliative Care Indicators Tool – Similar to Gold Standard Framework, in handy one-page summary.

Communication skills

MJA supplement – Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the

advanced stages of a life-limiting illness, and their caregivers. Clayton et al., Med J Aust 2007; 186 (12): 77 –

includes concrete examples of phrases to use.

Oncotalk - written resources & videos from USA; useful tips, not just for oncology patients.

(RACP videos - not yet available)

Educational resources (cont.)

Consumer resources

ePPIC has links to many approved consumer resources (for patients and carers).

Palliative Care Victoria – produces various brochures for consumers eg on symptoms

Palliative Care Australia – also produces various brochures eg What is Palliative Care?

Cancer Council Victoria – information for consumers specific to cancer

Better Health Channel – good resource in general for consumers, link is to specific page explaining Palliative Care.

MyValues - new website out of Barwon Health that allows patients (after free registration) to answer a series of questions that can assist in articulating their preferences and thus assist decision making. Final profile can be shared

with loved ones as well as health professionals.

Where to from here? – conclusions from Sept.

• Future projects

• How can we consolidate culture change?

• Continue with twice yearly meetings – variation on theme

– March 2015

» Project reviews

» Case studies and senior nursing perspective

– September 2015

» Project reviews

» Registrar perspectives

• Ongoing project support: strong endorsement from Board

ACSHQC – consensus paper