AUDIT OF ADVANCE CARE PLANNING (AND PPD) IN PRIMARY CARE

1. AUDIT OF ADVANCE CARE PLANNING (AND PPD) IN PRIMARY CARE Wendy Fenton (Secretary) Armita Jamali (ST3 Pall Care)

2. Background: • MVCN audit by C. Scholes, R. Allan, A. Bettany • Do patients referred to Specialist Palliative Care die where they wish? • Presented Oct 11 at MVCN away day, published Jan 12 • Main outcomes: • 60% of patients had known PPD, of these 82% achieved their PPD • 40% of patients had no known PPD, of these 76% died in hospital.

3. Background Continued… Few of the recommendations of the audit: Aim to increase numbers of patients dying where they wish by increasing conversations around PPD and systemic recording of them. This would increase patient choice and is likely to reduce numbers of patients dying in hospital, and increase deaths at home across this population. To expand audit tool into general practice as part of post death audit tool.

4. Background cont… Local Enhanced Service (LES) agreement for Palliative and End of Life Care: • Offered to all GPs in Herts, aimed at improving outcomes in palliative and end of life care in line with national and local guidelines, and improving patient experience and safety. • GP Practices have the option of signing up to LES (1 yr period), rewarded for extra work by payment. • Post death audit tool part of LES, so to be completed for each patient death by GP practices signed up to LES.

5. AUDIT AIMS: To audit whether ACP (including PPD) is done for patients in primary care - DoH End of Life Stratergy (2008) - RCP National Guidelines (2009) - GMC guidelines (July 2010) To audit whether patients with known PPD die where they wish To see if being known to Specialist Palliative Care Services affects above outcomes

6. METHODS: • Retrospective audit • Data collated from all Post Death Audit forms completed by GP Practices from 1st April 2011- 31st March 2012 (1 year) across Hertfordshire • Data specifically analyzed: • Was death expected or unexpected • Was patient known to SPC • Was Advance Care Planning done • Preferred Place of Death • Actual place of Death • If PPD not achieved, why not?

7. Results: • PDAT completed by 37 GP Practices in Herts • Total 133 GP Practices in Herts • 87 GP Practices signed up to LES • Total number of patients audited: 528 (386 West Herts, 142 East and North Herts) • 73% known to Specialist Palliative Care, 23% unknown • 67% malignant disease, 31% non-malignant • Death expected: 80% • Death unexpected: 8% • Death unexpected but not a surprise: 10% • 2% no answer

8. Results: Advance Care Planning

9. Results: Preferred Place of Death

10. Actual Place of Death

11. Results: ?PPD Achieved

12. Results: Why PPD not met?

13. Discussion: Advance Care Planning • 2x more patients started/ completed ACP if known to SPC (73% vs. 37%) • Over 3x more patients considered inappropriate for ACP discussion if not known to SPC (26% vs. 7%) • RIP prior to discussion in 25% of patients not known to SPC (7% known to SPC). However, 90% of patients death was expected/ not a surprise. • Overall 50% of patients not known to SPC were deemed inappropriate/ died prior to discussion (compared to 14% known) Is there a training need for non-SPC training in ACP, to increase confidence and timeliness of ACP discussion ?

14. Discussion: Preferred Place of Care • Pt numbers wanting to die in hospital (1%)/ unable to communicate/ not expressed similar for both groups. • >2x patients PPD in own home in known to SPC group vs. non SPC group (44% vs. 19%). ? Patients not known to our service not aware of provisions available at home • Significantly more patients with PPD at care home in not known to SPC group (26% vs. 6%)- conforms to what we see in practice, that pts in care homes often not referred to SPC as care homes can often provide certain level of EOL care. • PPD unknown significantly higher for not known to SPC group (a third of patients). This would reflect that 25% of patients in this group died prior to ACP discussion.

15. Discussion: Actual Place of Death • Limited analysis of data possible as APD question on PDAT form ambiguous. • Able to see that significantly more patients known to SPC than not known died at home or in hospice.

16. Discussion: PPD Achieved? • In those patients who had nominated PPD, 73% achieved PPD. • Results similar for patients known and not known to SPC. • So we can conclude that if PPD is known, patients have a very high chance of dying in their PPD (irrespective of SPC input)

17. Limitations: PDAT only completed by small number of total GP practices in Herts (37 of 131) Number of patients in audit 528 compared with around 9000 total deaths in Herts annually Not all deaths in the GP Practices recorded on PDAT (no mechanism to monitor this) Some Audit Pro Formas had incomplete sections

18. Limitations cont… • Audit Pro Forma section on Actual Place of Death ambiguous, thus extractable data limited • Not completed by all General Practices in Herts. Were those Practices who chose to take part in the PDAT as part of LES naturally more interested in Palliative and End of Life issues and so have better ACP/ PPD outcomes than we would expect to see generally in Herts?

19. Recommendations: • PDAT continuing to be distributed to GPs taking part in LES. Form needs to be altered to remove ambiguity in ‘Actual Place of Death’ and ‘Why PPD not achieved’ questions. • ACP training workshops to be extended to GPs- important to improve as per national guidelines • Yearly audit to ensure standards are improving