Post on 02-Jul-2015
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Acknowledgements
• Patients who assisted by their participation.
• Sarah Murphy & Caroline Lynch at
The Irish Hospice Foundation and The End of Life forum
• Training Practices at The TCD HSE GP Training Scheme
• K Doc, PHECC, Nursing Colleagues in Kildare
Dying in Ireland 2014
End of life planning
Dr Brendan O’ Shea Lecturer in General Practice
Dept of Public Health & Primary Care Trinity College
Introduction
• Family Doctor - Interest in end of life planning
• Part time involvement with Palliative Care Team
• GP Specialty Training TCD HSE GP Training Scheme
• Medical Director at K Doc (2008-2013)
GP feasibility / acceptability study ‘Think Ahead’
Nursing Home study End of Life Planning & ‘Think Ahead’
Today…..
• Tomorrow and the future…
Good End of Life Planning
When does it happen ?
Where ?
What would it look like ?
Why we don’t Think Ahead
• Cultural / Societal • Avoidance • Busyness • Fragmented Care (Good vs Poor Multidiscipliniarity)
• Legal uncertainties • End of Life Care is not a professional value.... • Professional inexperience / unease
Don’t know when to....procrastination
Why do we need to Think Ahead ?
• Avoid additional uncertainties
• Reduce costs
• Alleviate suffering
• It often feels good to !
When....How to...Where to....
When to Think Ahead ?
• Today !
• At 50 years of age
• At 4-6 weeks after a new/significant diagnosis
• Over 65’s – perhaps biannually
• On admission to a Nursing Home
Many right answers
Two wrong ones.... ‘Never’ and ‘Later’
When to Think Ahead ?
Shift the conversation from Pre arrest / Ventilated patient to several years earlier..... ……….Community The conversation / reflection works best for a
clinically stable, relatively autonomous patient
How to Think Ahead....
• Personal Experience
• Systematic use of ‘Think Ahead’ (www.thinkahead.ie)
Innovative end of life planning tool (2011)
End of Life Forum & Irish Hospice Foundation
Under constant development
Think Ahead
• How does it work ?
Think Ahead – in General Practice ?
• Feasibility / Acceptability Study 2011-12
• General Practice Setting
‘Think Ahead’ presented, followed by Telephone Survey
Participants advised to d/w friend or family
Dr Barry Brennan, Dr Oxana Bailey, Dr Frank O Leary, Dr Olivia McElwee Dr Dave Martin
Aim
Evaluate acceptability & perceived usefulness of
‘Think Ahead’ to patients in the
General Practice setting.
Method
• Observational study (5 Practices) TCD HSE GPTS
• Ethical Approval obtained
• Think Ahead presented to 100 patients
– Patients (40-70 yrs) presenting were recruited
– Clinically unstable patients excluded by their GP
– Telephone survey at 1 & 3 weeks.
Telephone Survey at 1 & 3 weeks
Did you read / complete Think Ahead ?
Any parts difficult / upsetting ?
Was it of interest ?
Did you discuss it with anyone ?
OK to get be given ‘Think Ahead’ in this way ?
Preference for paper or web based version ?
Analysis of the study
Strengths
Good variability
Good engagement
Good fit with practice
Weaknesses
Predominantly closed survey
Sampling
Response bias
Key Conclusions
Individuals are mostly well able and capable of engaging with end of life planning.
‘Think Ahead’ is a useful and available tool (DIY).
General Practice is a suitable environment to address end of life planning with patients.
End of Life Planning- Nursing Homes
• Controlled trial / waiting list / mixed methods
• Educational Intervention using Think Ahead
• 5 Intervention and 3 control Nursing Homes
• Key Outcome – Documentation EoL Planning
Intervention
Interactive NH Workshop, using Think Ahead
Dr Deborah Martin Dr Joe Marry, Dr Hugh Brady, Dr Connor Gallagher, Prof Catherine Darker
Focus Groups
2 Intervention and 1 Control Nursing Homes
Analysis Pending
General Practice SPICT & Think Ahead
• 4 Training Practices
• Screen using SPICT
• Offer ‘Think Ahead’ and review
Nursing Home
• Pilot Study using Think Ahead / PKB
PKB – Patients Know Best
In a national survey carried out in 2004,
67% indicated that they would like to die at home: deaths at home constitute only a quarter of all deaths in this country
Weafer
Where to discuss Think Ahead ?
• In the media / part of national dialogue
• Routine consulting – all over 50’s, in GP/PC
• On the confirmation of a significant diagnosis
• Part of good chronic disease management
• On admission to supported care environment
• In the company of a friend / family member
• With input from relevant professional advisers
• Sustained input from GP (Personal Physician)
Homework
• Complete Think Ahead for yourself
• Communicate EoLP as core professional value
• Challenge / advise all Clinical Staff
• Engage with Primary Care (Big Secret !)
Homework
• Engage with Primary Care (Shh!)
Homework
Engage with Primary Care (Shh!)
GP Liaison (?)
Local Primary Care Manager (HSE)
Clinical Seminar – Multidisciplinary
Reflect in your clinical administration
Ongoing Work...
• ICGP Blended learning consultation skills pack
• Use of Think Ahead in patients discharging from Med El Services
• Recording and Reviewing End of Life Planning Module in the EMR – Patients Know Best
Acknowledgements
• Patients who assisted by their participation.
• Sarah Murphy & Caroline Lynch at
The Irish Hospice Foundation and The End of Life forum
• Training Practices at The TCD HSE GP Training Scheme
• K Doc, PHECC, Nursing Colleagues in Kildare
Dying in Ireland….. Can we do better for ourselves ?