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 ?