Overview of the recommendations of the ACP short life working group

1. Advance /Anticipatory Care
Planning (ACP)
OCTOBER 2010
Sandra Campbell
Consultant Nurse
- Cancer and Palliative Care
Chair Sub group of SLWG3 on Advance Care
Planning
Sandra.campbell2@nhs.net

2. Advance Care Planning
 Department of Health (2006)
‘a process of discussion between an individual and their care
providers irrespective of discipline’.
 Working group definition (2010)
Advance care planning as a philosophy, promotes discussion in
which individuals, their care providers and often those close to them,
make decisions with respect to their future health or personal and
practical aspects of care.
These discussions should result in a documented
record of what the individual does/does not wish to
happen.

3. Advance care planning
Planning for end of life care can be done at any stage of life from
well to dying but usually through facilitated conversations that will
incorporate patient and carer choices.
Anticipatory care planning
Planning for situations including a change in health status we expect
or anticipate may happen to patients with chronic conditions
throughout the illness trajectory.
The outcome of both may be documented in an
Anticipatory Care Plan

4. Why the need for two terms?
 Along life’s journey, we do not just
develop a chronic condition, become
unwell and then die, we will often
have to face a very winding road with
death perhaps expected on more than
one occasion with difficult
conversations and decisions required.

5. ABCD of Dignity Conserving careABCD of Dignity Conserving care
(Chochinov, 2007)(Chochinov, 2007)
 AA -- AttitudeAttitude
 BB -- BehaviourBehaviour
 CC -- CompassionCompassion
 DD -- DialogueDialogue

6. ACP Toolkit (examples follow)
www.scotland.gov.uk/livinganddyingwell
 Umbrella for ACP
 Conceptual Framework
 ABCD practical guidance for Thinking Ahead
 Definitions
 Sample ACP plans and documents
 Core components
 Triggers for ACP
 SBAR and a range of other supporting documents
 FAQ’s
 Reference List

7. LLLeeegggaaalll PPPeeerrrsssooonnnaaalll CCCllliiinnniiicccaaalll
Advance
Statement
Self Management
Plan (with professional)
)professional)
Thinking Ahead/
Statement of Wishes
Anticipatory Care
Plan (ACP)
Advance Decision
Liverpool Care
Pathway
AAnn AAnnttiicciippaattoorryy CCaarree PPllaann mmaayy ccoommpprriissee aannyy oorr aallll ooff tthheessee..
Their completion will inform the Electronic Palliative Care Summary
Welfare Guardian
Welfare Power of
Attorney
Electronic Palliative
Care Summary/
OOH Handover form

8. A Conceptual Framework of Advance Care Planning – A Continuum of Opportunities
Well person Culture of open discussion about death, dying and spiritual needs. Dying person
Possible health/social triggers /Consider GSF / Prognostic Indicators eg PPSv2/ Assessment
tools
Health and social care professionals, Primary care team, Acute care team
Working
Reduction in risk of complicated grief
Change in health
status
Chronic condition
Sudden illness
Life-limiting diagnosis
Terminal diagnosis
Last few days
Making a will
Getting financial advice
Power of attorney
Social work involvement
Bereavement
Solicitors, Social Workers , Voluntary
agencies
Marriage or civil partnership
Buying a house Getting a mortgage
Getting insurance Education,
Faith groups Cultural groups
Advance Directive or Advance Decision Statement of wishes Thinking Ahead
Completion of Anticipatory care plan / Electronic palliative care summary / out of hours handover form/ LCP

9. ABCD of Thinking Ahead
 A = ACP
 B = Begin
 C = Communicate and Co-ordinate
 D = Delivery
Advance and Anticipatory Care
Planning, in practical terms are both
about adopting a “thinking ahead”
philosophy of care.

10. Change in health
status
Recognition of likely
life-limiting change in
condition and/or living
alone
Onset of a sudden
illness
Diagnosis of chronic
progressive incurable
condition
Death expected in
the next few days
Liverpool care
pathway (LCP)
Anticipatory care
plan
Thinking ahead
Statement of
wishes
Advance decision /
Advance directive
Electronic palliative
care summary
Out of hours
handover
Possible Outcomes of Anticipatory /
Advance Care Planning
Possible triggers
Change in carer
circumstances
Changes in home
circumstances
The triggers and the outcomes are
not necessarily sequential and the
processes to be implemented
should always be the result of
considered clinical judgement and
include discussion with the
patient/carers
By adopting an advance care planning philosophy, the right care
will be given at the right time by the right person with the right
outcome to the right quality standard.
Possible triggers for implementing the philosophy of Advance
Care Planning

11. SBAR communication tool
 S: Situation
 B: Background
 A: Assessment
 R: Recommendation
Haig et al (2006)

12. Support for ACP
 The development and implementation of ACP
had been supported by a wide range of
national and local policies and guidelines.
 There is also a growing body of academic
literature in support of ACP however this
does need to be evidenced by robust
research.

13. Potential benefits of ACP
 Patients receive the care they desire
 Appropriate management
 Support for decision making
 Reducing the risk of complicated grief

14. Summary of RecommendationsSummary of Recommendations
1.1. Advance care planning needs to be accepted as anAdvance care planning needs to be accepted as an
overall concept covering an umbrella of terms andoverall concept covering an umbrella of terms and
processes including anticipatory care planning forprocesses including anticipatory care planning for
patients with Long Term Conditionspatients with Long Term Conditions
2.2. Agreed definitions essentialAgreed definitions essential
3.3. Engagement with whole population necessaryEngagement with whole population necessary
4.4. Core components need to be contained within anyCore components need to be contained within any
documentdocument
5.5. Coordinated education critical to implementationCoordinated education critical to implementation
6.6. Suggested use of tools such as SBAR communicationSuggested use of tools such as SBAR communication
tool and electronic palliative care summary to supporttool and electronic palliative care summary to support
communication between teamscommunication between teams

15. Recommendations contd.Recommendations contd.
7.7. Formal audit and evaluation of any documentation,Formal audit and evaluation of any documentation,
following death to assess outcome of ACPfollowing death to assess outcome of ACP
8.8. ACP discussions should contain components asACP discussions should contain components as
recommended by DOH (2007) and DNACPR andrecommended by DOH (2007) and DNACPR and
organ donation as appropriateorgan donation as appropriate
9.9. ACP should be considered on admission toACP should be considered on admission to
Nursing/Care HomeNursing/Care Home
10.10. In applying ACP, there may be 3 types ofIn applying ACP, there may be 3 types of
documentation, Legal, Personal and Clinicaldocumentation, Legal, Personal and Clinical
11.11. Local arrangements should be in place to ensure anLocal arrangements should be in place to ensure an
updated copy of the anticipatory care plan is with theupdated copy of the anticipatory care plan is with the
patient/carerpatient/carer

16.  An Advance/Anticipatory Care Planning philosophy isAn Advance/Anticipatory Care Planning philosophy is
advocatedadvocated
 A coordinated approach to education is requiredA coordinated approach to education is required
 A collaborative approach with improved communicationA collaborative approach with improved communication
with patients/carers and between teams is crucialwith patients/carers and between teams is crucial
 The transition fromThe transition from livingliving with a chronic condition towith a chronic condition to
dyingdying will be as seamless as possiblewill be as seamless as possible
 The vision is for equitable care for patients with longThe vision is for equitable care for patients with long
term conditions and those at the end of life to facilitateterm conditions and those at the end of life to facilitate
the right thing being done at the right time by the rightthe right thing being done at the right time by the right
person, to the right quality standard with the rightperson, to the right quality standard with the right
outcome!outcome!
In ConclusionIn Conclusion