Desktop Helper 3 - Supplementary Information 3 - Advance Care Planning Tips for Primary Care Professionals

S3: Advance Care Planning Tips for Primary Care Professionals
Reproduced with thanks to Dr Patrick McDaid Islington GP, London

Advance Care Planning (ACP) is designed to help patients and families think about the future and times when they are unable or too upset to make considered decisions.  It is never too early or too late to start or update an ACP discussion.

• Take opportunities as they arise.
  Don’t wait for perfection. An ACP conversation (and documentation) can evolve over time.
• I’ve opened the box but I don’t have the time/skills to deal with what’s come out. You can reschedule: “Sounds like we should make time to talk about that properly” or reroute “I know/can find out who can help you with that.”
• Fear or discomfort talking about ACP is common but most patients welcome the opportunity. Remember it is more than just End of Life. The palliative care approach begins with goal setting and current care and extends through the End of Life.  It is not uncommon to lack confidence initiating an ACP conversation, but most patients and HCP  report relief and satisfaction afterwards. See www.dyingmatters.org/gp and “Go with the flow” below.
• The key environment is inside our heads - there is no single “right time” or “right place”.  Any visit or opening should be considered.  Some times like follow-up after an exacerbation or hospitalization may be very opportune times.
• Asking permission/agreement engages the patient and family. Make sure everyone is aware of available options and then it is useful to ask what they think of that option.
• Document and share. People with COPD often receive care from multiple HCPs and it is a missed opportunity if you do not share what you and the patient and family have developed.
• The format of what you share will vary by where you are: it might be the family physician record, or Out of Hours handover or living will or patient-held online record. What matters is that it is recorded, available to other HCPs and that the patient and family have a copy.
• Go with the flow. Listen for opportunities and comments from patients and families and follow through - either immediately or schedule a follow-up appointment to discuss.
• It takes practice, so try it and keep trying. As long ago as 1969 Elisabeth Kubler-Ross found that physicians were the most uncomfortable with discussion on death and dying.  In most cultures patients and families are ready at some point.
• In difficult terrain wear comfortable shoes or use phrases others found helpful to start and then individualize. See section 2 for a list of questions.
• Remember, a strength of general practice is continuity and longterm care. A strength of primary care or general practice is that rapport builds over time and conversations move forward in a series of interactions, not a single visit or discussion.

An Example in practice: ACP in 5 minutes

This is based on a real consultation that took 5 minutes. Honest !! The more time and space the better, but you may be surprised at the number of opportunities to do something, or get things started within a limited time frame. At the end of a nursing home visit I was asked to see a 78 year old man with chronic renal failure who had recently been discharged from hospital. He attended dialysis three times a week and had been admitted from the dialysis unit. He was treated for pneumonia with intravenous antibiotics. Now three days post-discharge his breathing was again deteriorating. The hospital discharge letter was brought to me along with the patient who was wheeled in a wheelchair. He had signs of a chest infection and mentally had his full faculties. I thought I should prescribe oral antibiotics but also that they might not be sufficient to avoid a hospital admission. I had just been to a local End of Life Care event advocating the involvement of patients in decisions about their care. It would not be long before my afternoon session would start and I had not had lunch. So the dilemma. Antibiotics and run, or open up a conversation with the patient and come to a joint decision. Did I have the time? My energy levels were dipping. I went for the conversation….which was surprisingly short.

• Dr: It looks like you have another chest infection. I can treat you here with the same antibiotics you had intravenouly in hospital. Would you be happy with that?• A: Yes
• Dr: You should get better but you might not. If you weren’t improving we would normally send you back to hospital. Would you be happy with that?
• A: No
• Dr: Is that the case even if your life was at risk?
A: Yes
 

Touchingly he made a small salute, tapping his forehead as he was wheeled out backwards in his wheelchair. I managed to grab some lunch and the Out of Hours Handover form was completed after my primary care session. The brief conversation meant that I was confident that a recommendation he was “not for CPR” would be in line with his wishes. He survived his chest infection but died peacefully one week later having declined further dialysis, repeatedly saying “Not today” when the ambulance came to pick him up. The nursing notes indicate he remained in good spirits. This encounter was outside my comfort zone but my comfort zone increased as a result. Go and increase yours.

Patrick McDaid
2012
Reproduced here with Dr McDaid’s permission

Additional reading material recommended by Patrick McDaid

Courageous conversations for GPs: Getting the Ball Rolling

Courageous conversations for GPs: Golden Nuggets (Tips for Difficult Conversations)