02 Apr End of Life Care
The practice of medicine must adapt to meet evolving practical and ethical challenges of an aging population, in addition to ongoing improvement in the technological capacity to prolong life. To meet these challenges, doctors need to incorporate better care at end of life into routine practice.
These issues were addressed at a roundtable convened by Melbourne and Monash Universities in conjunction with The Australian Centre of Health Research. The panel included diverse health professional leaders assembled in Melbourne early in 2013. These representatives were from backgrounds of legal, political, medical, surgical, general practice, healthcare administration, consumers, the Australian Medical Association, ethical and academic groups. The panel engaged in vigorous discussion to identify practical solutions to improve end of life care and how to engage community and political support. This paper is a summary of that discussion.
Community engagement, legal cohesive supports, workflow processes. the key recommendations were:
1. Enhanced leadership and education in respect to end of life care in healthcare profession and the wider community
Medical leadership and education:
- Greater coordination of care by generalist clinicians for complex elderly patients.
- Provision of training and resources for general practitioners for better care.
- Medical specialist colleges (i.e.: surgery, physicians, anaesthesia and ICU, psychiatry) should include end of life care communication and decision making training in their curriculum and revalidation processes.
- Senior practitioners (within universities, hospitals and colleges) should demonstrate leadership in collaborative patient-centred care.
- Greater support for junior doctors to improve communication skills, recognise dying patients and enact appropriate and timely changes in goals of care.
- Improved availability of documentation regarding treatment limitation and advance care plans for MET (Medical Emergency Team) calls.
- Partnering with care facilities to educate nursing home staff to provide ACP.
- Enhanced research into prediction of poor quality outcomes, and longitudinal studies of elderly patients undergoing surgical procedures.
- Ensure clarity and consistency in explaining the scope and purpose of advance care directives and application in different clinical settings.
- Partner with profit and not for-profit groups for public awareness campaigns similar to ‘Engage with age’. • Use senior Australian of the year to talk about quality of life, medical wills and ACP.
- Creation of a central ACP website and educational videos to promote and educate patients about ACP for use in medical waiting rooms and other healthcare sites.
- Research into effectiveness of possible public policy and campaigns; encouraging the use of social media to improve awareness of the issue.
- Creation of a ‘TED talk’ (a not-for profit website based on technology, entertainment and design to spread talks and ideas, www.ted.com) about a good death to increase community understanding and promote discussion around quality end of life care.
2. Improve implementation of Advance Care Planning
We need to implement Advance Care Directives (ACD) at appropriate points in the care pathway and ensure that these are respected and followed by clinicians and recorded in and up to date format for easy communication.
- Support for general practitioners to perform advance care planning with trained advance care planning educators.
- Use of teleconferencing and other IT solutions to support nursing consultations with patients in their home.
- Ensuring ambulance staff request ACP documentation for patients and/or take smart phone copies of plans to emergency departments.
- Create a national registry for ACP with patient controlled electronic health records.
- Creation of incentives for people to initiate ACP at health-related life events: e.g. during annual health check, private health insurance renewal, organ donation, admission to nursing home, writing a will, driver’s license renewal (see Table 1).
- Engagement with private insurers to add ACP services upon renewal of private health insurance, and to promote education for patients with referral to medically supported websites.
- Improve recognition and application of Advance Care Planning (ACP) in the acute care setting.
- Standardise criteria for treatment limitation documentation in hospitals.
- Ensure early two-way communication of advance care plans with general practitioners and aged care provider.
- Encourage use of ACP practitioners for in-patient and out-patient hospital referrals
- Incorporate ACP discussions into pre-assessment clinics for surgery and outpatient chronic disease clinics and rehabilitation units.
- Incorporate ACP to surgical consent process.
- Include ACP on hospital discharge information for GPs.
- Audit and follow up on implementation changes.
3. Improved policies and governance within the healthcare system
Support acute system changes for advance care planning in the community and hospitals.
- Ensure consistency of national legislation regarding end of life care and Advance care planning.
- Implement recommendations from recent Reform for the Guardianship Act Jan 2012.(eg. section 11.38)
- Support education of legal professionals regarding the scope and purpose of Advance care directives. (ACDs)
- Include standards for hospitals and health care facilities to offer support and respect Advance care planning and accreditation requirements.
- Provision of resources and funding for palliative care across acute, community and private and public sectors.