GP toolkit aims to make advance care conversations easier

Doug Hendrie

29/07/2019 3:05:36 PM

Planning ahead for the end is essential to avoid sending families into crisis, expert says. 

Palliative care expert
Professor Josephine Clayton is determined to help patients plan ahead for the end.

The idea came to her from difficult circumstances.
In her work as a palliative care specialist, Professor Josephine Clayton would regularly treat patients nearing the end of their lives. 
But many had not made their wishes clear through advance care planning. Now they could no longer communicate.
That left their families in crisis, forced to make difficult decisions about their loved one as they neared the end. Many felt guilty.
‘I was seeing people who end up in emergency in a crisis situation who hadn’t had a conversation with their loved ones or their doctor about their wishes if they were in a situation where they couldn’t speak for themselves,’ Professor Clayton, a Director at the Centre for Learning and Research in Palliative Care at HammondCare, and Professor of Palliative Care at the University of Sydney, said.
‘I was also seeing people who were living with a chronic progressive disease who were continuing their trajectory of treatment without anyone really looking at the big picture and saying this person might be at risk of deteriorating and dying.’  
The difference was stark when patients had conversations with their GP or palliative specialist to put advance care plans in place.
‘There’s a huge difference. It’s chalk and cheese in terms of the family’s readiness, the person’s readiness. And it allows time to establish that rapport,’ she said.   
The challenge, of course, is how to start these difficult conversations about end of life planning with patients.
In response, Professor Clayton and colleagues started the Advance Project, a RACGP-accredited evidence-based toolkit and training package to help GPs, practice nurses and practice managers get involved in advance care planning, and assess patients and their families’ palliative care needs.
The project began with nurses, and is now rolling out to GPs and practice managers.
‘We realised how incredibly busy GPs are, so we thought if we can get the whole team involved, it will make it more feasible,’ she said.
‘We’ve had over 500 nurses complete one or more components of the training, and we could show they had significant improvement in their knowledge and confidence around advance care planning and palliative care, and significant change in their practice. They were much more likely to have a conversation.
‘GPs get the satisfaction of knowing the person they are caring for will have care in accordance with their wishes, [and] that interventions won’t happen to them that they wouldn’t have wanted.’
The training tackles the challenging conversation by breaking it down into manageable chunks – and outlining opportunities to raise the topic, such as during a health assessment for patients over 75.
‘It’s a big step to just jump in to talking about this, so we’ve made a step in between,’ Professor Clayton said.
‘We developed a structured screening interview that nurses can use in routine health assessments, which assesses a patient’s readiness to discuss advance care planning. If they’re ready to discuss it, the nurse can give them resources so they can go away and talk with their family, then come back for a further discussion with the nurse or GP.
‘There’s a really big need for this. Often people think about this when a loved one is about to go into an aged care facility, but then they’ve often lost the capacity to take part in decision making. By then it’s often too late. People might not be ready straight away, but planting that seed is crucial early on.’

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Graeme Burger   5/08/2019 10:12:55 AM

Call it "The What if" conversation, as in " At some stage we need to have the what if conversation, Do you want to do it now or some other time when you have other people you want involved present".
Once the "what if" conversation is finished then put it "in a box" that can be opened at any time by either patient or doctor but otherwise put the focus of conversation on the here and now.
All we ever have is now....
Graeme Burger