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everybody, including healthcare professionals, always just feels like a very sensitive type of subject to kind of approach. So I really hope that this talk will help refrain this in your own minds, too, that it's never too soon and that you can learn to equip yourselves with the skills to do advance care planning. Well, uh, and then they're sensitive and compassionate way. So I I don't know exactly who's here. So it would be very helpful to me if you could just quickly use your slide. Oh, to let me know who you are. And I'm hoping this is going to work out and I can see Oops, sorry. All my slides are slipping. Who is here? Just so I get a sense of who I'm speaking to and at what level I'm pitching this, that I think whoever you are. So I'm hoping that you'll get something from this. Um, as with all the technology, I'm not sure if it's working. I'm not really getting anybody through, so I'll just leave that for another couple of seconds. But it might be the side. Oh, great. Thank you. I can see somebody in so perfect. It just means that the other few slides where I've got slider. It should work as well, so there should be a cure code and a code to join if you can, right? I don't want to waste lots of time. So let's see. I've got to very intrigued about none of the above. We'll see if I'm pitching this right for you. Hopefully, okay, I'll leave it there because I don't want to waste too much time. But hopefully this will be I will try and change it a little bit to kind of match who's on the call? So really, from today we're going to be looking at what advanced care planning is thinking about the benefits of advanced care planning, Um, then thinking a little bit more practically to apply some relevant communication skills to do it well and then also described possible outputs of advanced care planning and when and how to use them. And I have to say, if there is anybody from sort of an international audience, then actually what we're talking about today is very UK focus based in UK kind of law. So it would be about going away and just checking locally, Um, what you have. And I guess the other caveat is that I'm speaking from a very unfortunate English centric view as well. I know that there are slightly different kind of terminology in Scotland. I did train in Edinburgh, but now I've lost or forgotten all of the different kind of wording, but the principles are all the same, but you might just call them slightly different things. Okay, so what is advance care planning? So this is when you can go back to your slide. Oh, please. Um, I always find that I learned a lot when I'm teaching from everybody else that I am actually teaching. So please do, um, participate. So really, this is what what is advanced care planning to you. And then I've kind of broken that down a little bit if that helps. So what are the components of it and what do you need to do to make it effective? It's all coming up in separate words, but I'm assuming helping different patients decide. It might have been a full sentence. It might have just been a single single words, which is absolutely fine, but yeah, it's about patients about this, about deciding, helping them decide. All right. I can see a few people time. Okay? How we can explain to illness about patients, about their illness, patients in daycare. Perfect bit about autonomy there and decisions. Okay, great. It's a really good grounding there. So I'm going to just throw up some long winded definitions and try to highlight the bit. I think the most important. So this is really from a, um, what they call like a Delphi survey where they go and ask people who are kind of experts in advance care planning what they think should be included in the definition, and they kind of come up with it together as a group. So this is kind of terms of international consensus, because I've asked people from all different countries around the world. So it's a process that supports adult at any age or stage of health in understanding and sharing their personal values, life goals and preferences regarding their future care. And the goal of advanced care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness. Okay, so the reason I kind of highlighted some of these terms, I'll come back to you, but we've already got an understanding that actually it can be any for anybody. They don't need to be kind of what you think is terminally ill in the last year of life, for six months of life. It can really be anybody. It's a process. It's not necessarily one event. It's not a tick box exercise. It's, um, something a little bit more kind of interactional, and you've got the goal there of what we're trying to achieve. So the this definition has come from the universal principles of a CCP, which is a U. K based document that came out earlier this year. So it's a voluntary process of person center discussion between an individual and their care providers about their preferences and priorities for their future care. While they have mental capacity for meaningful conversation about these, the process which is likely to involve a number of conversations over time, it must be must have due consideration and respect for the person's wishes and emotions at times. So again, it's this kind of building on this idea that it can't really be forced on somebody. It's not something for us to say yes, we've done a tick. It really is coming from the patient themselves and then wanting to be involved in the process, said, Just to say a little bit about this universal principles, you can find it if you if you just type it into Google. But it really is a lot of kind of UK based organizations coming together and saying what they feel. The underlying priorities are principles of advanced care. Planning should be so you can see that you've got the NHS. You've got professional colleges and institutions like the B M A, the Royal College of Physicians. And then you've also got patients facing charities of patients have been involved in drafting these. So I'm going to go through the principals now. You probably will find that they seem really kind of broad and overarching. And I think that's the point that they should be able to be applied. Absolutely. Everybody Okay, First one here is that the person is central to developing and agreeing their advanced care plan, including deciding who else should be involved. Okay, so I saw from your word cloud that the person and the patient was really important. So we've got that one ticked. Okay, so the person has personalized conversations about their future care focus on what matters to them and their needs. So again, just a very a very clear idea that you know it's not about having a script. It's really about making each conversation individualized to that person. The third one is that the person agrees on the outcomes of the conversation through a shared decision making process in partnership with relevant professionals. Okay, so again, it's not about us telling people what we think is the best thing for them. It's really about them also agreeing with what's being said. Yeah, so this is a bit that really makes it something practical and useful for people. So the idea is that it's a sharobel plan that records what matters to them and their preferences and decisions, because if you have a discussion and it's not shareable, it's actually very little use or less use, especially if that person is going to, you know, come into play when they're really unwell. They can't advocate for themselves. And if that discussion is only happened between you and them and you're not there at the time it's not written anywhere. Nobody's going to know. Okay, so the fifth one is that the person has the opportunity and is encouraged to review and revise their advanced care plan. So this really stems from the idea that actually we know that people can change their minds. And in fact, I think about 30% of people do change their wishes as their illness progresses and you know their life changes around them. And you know what they may have wanted in the past. Maybe not what they want now. So even though it's a difficult discussion to have, the idea is that there should be opportunity and people should be encouraged to review. Um, and you can always use opportune moment if somebody started having lots of hospital admissions or if they've had to move to a nursing home. These are always times where it might be a good point to review because there's been a change in their illness, probably significantly that some of their decisions might have changed. And the last one is that anybody involved with advanced care planning is able to speak up if they feel that these principles are not being followed, So this idea that you know, if they feel either people are being coerced or that they're getting under the influence by somebody, which I guess is the same thing, that you're able to speak up and report it to sort of somebody. So those are are universal principles, I said, really kind of broad, Um, but actually, when you kind of think about them all, they should still be applicable to every single person that you have advanced care planning discussions with. So let's think about what the benefits are of advanced care planning. So I think I'm just going to refer a little bit, too research and why Research on advance care planning has is so difficult to do and really to distill out. I can't just come and list. You know it's good for a, B, C and D, and the reason is that a CP is really considered a complex intervention. So you've got lots of interacting components, lots of variable behaviors by everybody involved. You can target many different people or organizations with it. Um, there's lots of potential outcomes as well. So what are you going to be measuring? And how? Because usually in studies, you've got a primary outcome that you're mainly looking at and some secondary outcomes. And actually, with advanced care planning, there could be so many outcomes. How do you choose? Um, and it's a sort of intervention where you have to have a degree of flexibility of how you administer it. So it's not like a medication that is going to come in this tablet form at 40 mg, and it's going to look like this and you're going to give it this time, Um, and take it this time every day, you know, because it's a personalized process. The delivery to every single person is going to be slightly different. Okay, so this Who's delivering it? Is it a GP? Is it somebody hospital? Is it a specialist? Is it a doctor? It's also who's receiving it. So are they healthy people over a certain age? Are they people who have, um who are felt to be in the final year of life? Are they oncology patients? Are the heart failure patients again? So just a lot of differences when it comes to looking at the literature, how is it delivered? We've already talked about that a little bit. Where is it? Are you in an inpatient and outpatient at the home? That sort of thing might change how people receive advance planning conversations. When is it delivered slightly linked to kind of selecting who you are, what type of patients you're you're targeting. And what is advanced care planning. So is it just the discussion that you're thinking about? Or is it filling out some paperwork specific paperwork that you're kind of measuring? Um, are you trying to get them to nominate a proxy person or LP? And also, as I said, in lots of different countries, they got lots of different legal frameworks, so that what in what people are measuring are going to be different depending on where they are. So when it comes out, down to the literature is really hard to do is, you know, a systematic review and pull everything together and, like, spit out exactly why it's good. But there is evidence, really. That is kind of a very multilayered intervention, that there are many people and services and also society that benefits from this kind of approach. So obviously, as a person also families and carers, you're going to be a little bit more confident, knowing what that person's wishes are. They feel like they've got a little bit more control over their their lives and what to expect in the future and then for healthcare workers. So for all of us, um, the idea is that you kind of know that you're delivering personalized care because I think at the end of the day, a lot of us want to be able to deliver that. But we just don't know what people want. Um, it has been shown to sort of reduced burn out this idea that you you are a little bit more comfortable with what you're doing. It's not that kind of moral injury that you're doing something you don't think you should be doing. Um, there's a reduced conflict there, really, for conflict, reduced potential for conflict and misunderstanding between either patients and also carries, and families which cause a lot of stress and can be quite hurtful and upsetting to us and then broadly in terms of services, you know you'll be able to plan your healthcare services better if you've got an idea of what your population wants, and you might have a more efficient and effective use of your services because you're not. You're using them on the people who want them and not using them on the people who don't want them. And as a society, it just generally promote this idea of either living well, um, improving quality of life, having those kind of more difficult discussions and being as a society, being a little bit more aware of illness and dying. And all of that is seen as a good thing. So we're just going to move on to the more kind of practical aspects of things. So maybe helpful approaches or phrases and again, I'm gonna ask you what you either like to do yourself or what you've seen other people do, um, to start an a C p discussion. Because, actually, I think this is the bit that people really struggle with. How do you actually start approaching this kind of topic with people right to possibly see some similarities between that one and something I put in the future slide so lovely. Okay, When the opportunity arises, I guess the difficulty thing about when the opportunity arises is that, you know, are we as healthcare professionals kind of picking up on all the little nuggets that could be picked up on. And actually, when push comes to shove, do we find it easy then to actually start talking about it? Use a trigger. Great. Okay, just see a couple of people more typing, so let one or two more suggestions come up and then we'll move on. Okay? So checking patient's understanding, we'll look at a few kind of phrases. If people are wanting specific kind of phrases to use, I think I will move on. But thank you very much for everyone has contributed. And if you're still typing, sorry to cut you off. Feel free to copy and paste into the chat if you want to share it. So my next slide, hopefully it moves on. Oops, I'll just go back because somebody has managed to put when family members partners make decisions such as going to a nursing home can be a prompt. Perfect. Okay, let me go back. So this slide is looking at research. Where people have gone in with an audio recorder into hospice is specifically, I guess, this one. This research been taken from and recorded how palliative care doctors start speaking about the future or try and introduce the topic to patients, and and then they go through the conversation really in depth detail and try and pick out what the patterns are. So the first thing that comes up that people do quite early in the conversation is this thing called fishing. So they follow up on patients descriptions of problems or symptoms and asks for sort of associated thoughts and views. So, for example, when the pain's bad, can you remember what's going through your mind at the time? Or when the oncologist said that? What did you think? So again, it's the patient may not be talking about end of life issues at all, but it might be if you're wanting to try and start introducing the subject, just to see if there are those sorts of thoughts going through the patient's head at specific times. So usually picking up on when symptoms are bad or if they've been told specific news. Okay, um, I think somebody had kind of mentioned this in terms of opportunities. I think a lot of these opportunities, so these are ideas that you can use to find your opportunities so you said so for example, coming back to what you were saying before, Part of it is, is it the fear of what might happen? So again, using words that the patient has used always makes it easier for you. So you're not introducing difficult language into the conversation, Okay? As you, maybe you've tried your fishing question, you might have tried, and you said you want to kind of get a little bit more direct. So, um, for example, you could ask, Do you ever wonder what will happen if they don't have treatment that works? So you're really directly pointing them into the direction of Okay, We're reaching a stage where there aren't very many treatments left to reverse whatever process is going on. It was found in the research that generally there's no real overt mention to dying or death, but they draw on some of the language. As I said, that all kind of topics have been brought out in the conversation already. The next one is the use of use of the hypothetical situation. Um, so again, this is usually probably already when you've navigated your way in and you're already on the kind of right topic area. Um, but it could be something along the lines of If there was a situation at home where you were so unwell you could not make a decision at the time. And the doctor felt that coming into hospital was unlikely to improve things. Where would you want to be cared for? You know, you can answer, ask you a question after that, Um, another one that I've used as well for a young lady who had come into the hospice quite a few times for symptom control. And I could see a big difference in her this time. And one of her concerns was that she never really involved her parents all that much. She felt it was going to really upset them. But I was now worried that actually, this may be her final hospital admission. I didn't think that she was going to, you know, um, survive the hospital hospital admission. So I said to her, there may come a time when there are no more treatments to reverse what's happening and that time maybe short. And by short, I mean days and I you know, I don't know when that time is going to be. Maybe it's a long time away, but I just want to check it when that time comes, Would you want us to call your parents and let them know what's happening? And she said yes. So it meant that sort of later on in her admission, I actually don't think it was. I think it was a day or two. Afterwards, something changed and she was very breathless. And I said to her, You know, when I was talking about that time when we may not be able to reverse things anymore, she said, Yes, I said, I think I think that's about the time So it helped me when the time came to really deliver difficult news. I could just refer back to something I said before and it meant that I knew what she wanted. I knew that I could call her parents, not feel guilty or bad that I had done it because I knew that's what she want me to do and then the last one This is kind of again zoomed out against direct task is really asking them specifically about them. Hypothetical situations are putting them in a potential future situation and this last one is again just making really general statements about people and illness. So, for example, sometimes when people have been in hospital several times over a short period with similar problems, it means that it's getting harder and harder for the doctors to find a treatment that works. So you know, you're not saying you we're just making a general statement and hoping that the patient that you're speaking to the family are kind of drawing parallels with themselves and see if that allows you to transition into speaking more personally about them. I recognize that the sun is going down and I've got, like, a little lump on, and hopefully I'm not now all dark to you, but because I can't see myself, Okay, So for people who are actually looking for actual phrases to use, I know that with time you will develop your own kind of patter, things that feel comfortable to you. But sometimes you just do just want to know. Okay, give me a little stock phrase. It's easy for me to try and remember and practice with. So the first bit about starting the conversation Somebody mentioned it, um, on the side and it's really I always think the first bit is to find out where your patient or their family or whoever you're speaking to is really at, because it will give you so much information about how you where you pitch it if you think they're even ready. So you're assessing that readiness for the conversation. And these are the types of phrases like you used to tell me what you know about your cancer, your heart failure, your emergency room disease. Okay. And I think specifically and it's very subtle. You're asking about their cancer. So what you know about your COPD? Because obviously everybody's experience is very different. Everybody's trajectory is very different. So you're actually trying to get them to really start thinking about themselves? Very subtle. But there and the same is for these other ones. So what have you been told before about what to expect with your Parkinson's, for example? Okay, and this last one is probably doesn't always work as well. Um, sometimes people don't really know what you're talking about, but I feel like if somebody has either been in the hospital quite a few times or something like that, you know, What sense have you made of coming into hospital three times in the last month? Just again, it gives you an idea of what they think it's been happening. Um, but that last one, I feel, can only be used in particular circumstances. But it might be something that is useful if you just need to try and pull something out of the bag. So after you've kind of heard from them what they're thinking, Um, my next slide is about really starting to talk about what advanced care planning is about, and you'll see that the wording is very similar to what somebody has previously put. So some people find it helpful to talk about what they may want or not want in the future when their health changes. And then you can follow that up with something like, Do you think that would be helpful for you, or have you had these kind of conversation before? So again, the things I point out here is that I used some people a lot, Um, because it's in some ways legitimizing the way that person may or may not be feeling. They could say, Yes, that is me or they could also. No, that's not me. Um, you know, some people find it very hard at this stage to see their loved one not eating and drinking. So well, is that true for you? And I say that the families a lot because then they can say, Oh, no, no, no, no. We know we've been through this with whoever else. We know that at this stage, um, you know, they're not They're not eating and they're spending all the time sleeping or whatever. And you're in a completely different place to somebody saying, actually, yes, I was really worried about it, and I'd like to talk about it. So there's some people Phrasing actually helps a lot of different ways. Um, but I do like to use it to kind of either normalized or legitimize the way somebody might be feeling. Um, also focusing on May or May May want or may not not want. So again, it's this kind of idea that there are both options available to talk about, um, and being a bit specific about the future when health changes. So again, you're not saying that things are getting worse necessarily. You don't need to panic somebody into thinking that they're immediately going to deteriorate. But when health changes so again, just keeping it kind of vague like that, I found, is slightly more helpful and means people are kind of a little bit more help and more willing to continue with the conversation. So the next bit thinking about assessing readiness of the person. So this first one is about double checking. So I'm thinking in situations where you know, the patient may have said something or family have said something that catches you off guard off guard. And you think, Oh, or I want a little bit more time to think about this so classically they may suddenly just come out with, you know, how long have I got left or am I dying? Sometimes these sorts of questions can just come out. And so I acknowledge, I always say, I'll answer your question honestly, But first, can I ask? Okay, so again, you're just double checking because there's some people who say how long And then when you double check, they said, actually, I don't really want to know, but I asked because or they might actually be hoping to reach a specific event. They don't need to know. They don't really want to know the rest. But they just want to know if they're going to make it to the wedding in two months or something like that. So I do use that opportunity to not only by yourself a little bit more time, especially if they've asked you. And you're thinking, Oh, gosh, I wasn't ready for that. But also really double check that they want to know the answer. Okay, so I'll answer your question honestly. But first, can I ask what you've been told about this before? Why did you ask that question? How? Well, knowing the answer, change your decision or what do you think the answer will be? So again, it's kind of putting it back on them in some ways to test where they are to know to make sure that you're not going to completely, you know, come left field. Because I've, you know, seen people who say we know that time is short. And I asked them, What do you mean by short? And they say a year. And you know, when I say short, I mean days. So it's again just really being curious, I think, is the is one of the the take home points there. So another thing accessing readiness is this one if they change the subject. So you know, if you've done that fishing and you've done the you said and you may be asked a direct question and they've kind of skirted, skirted away a little bit a few times, they'll start talking about Oh, well, the oncologist said, This this this is this and they're not really answering the question or they talk about their family or something. Note it down in your head because that's what the sort of thing I would be recording in the notes that they're not ready to talk about all that. You You You broach this topic twice, and each time they change the subject, it just gives. It makes it clear to whoever is reading it the kind of context of the conversation that was happening. So I would usually try. Try a topic two or three times to introduce into a conversation and see, see what happens, and if they deflect, that's not the right time. Top the conversation, then you've got people who you know directly refuse to say I don't I don't want to talk about that. I don't wanna, You know, talk about the future. I don't want to think about getting worse. And so again it's acknowledging that you heard them. I hear you don't want to talk about getting more and well, so we won't go there. But can I check if there's something that you have been worrying about that you think would be helpful to talk about talk more about So it's a little bit wordy. You can probably cut that out a little bit, but it's this idea that you acknowledge that they don't want to talk about it but still give them the opportunity to raise anything that has been worrying them, because you may find that they still want to talk about some aspects of it. So my next one is a little bit of a tip of People are hesitant about talking about specifics. So actually, this idea of knowing people's values preferences to help you make decisions or somebody to make decisions on their behalf in the future when they can't these are the sorts of things that might help you. So when making any decisions about your health care or treatment. What sort of things influence your decision? So if they say you know how long I'm going to be a hospital, or how likely it is that the treatment's going to work, whether it's gonna be a problem for my family, whether I'm going to see my family, all these things, you're already building a picture of them that will help you or somebody else make a decision in the future. And you're not even mentioning the health, them getting worse than becoming more and, well, this is a really general question. So sometimes a nice one to do. And actually, just from building a rapport with a patient learning more about them, it's a good one to use. So similarly, what would a good quality of life look like? Or what would a bad quality of life look like? So you get an idea of where that kind of level of comfort and where they see themselves in the future, so kind of summing all of it up a little bit? And some of you may be familiar with this book, and I think one day he's an American surgeon. He's a brilliant book about sort of people nearing the end of life, and a lot of it really is basically advanced care planning. And he has these sort of five points that he thinks it's really important to ask your patients. So, as we said, understanding of where they are in their illness. Okay. What? Your fears of worries for the future. What are your goals? Are priorities What outcomes are unacceptable to you? What? What are you willing to sacrifice? What would a good day look like? So some of it. I mean, we've kind of covered all of those. Um, but that's how he distills everything into 55 points. That would be really helpful to know and still read. The whole book is very good and again kind of summing up this section. I'm going to go and cover what my I think my top tips for effective conversations are not just advanced care planning conversations, but generally when you're speaking to somebody, especially if they're more difficult topic so creating a sense of time, we're all really busy. Even within palliative care, we are relatively busy. Yes, we do have a little bit more time to have some conversations but a lot of it can also just be about how you create that sense of time. So sit down with your patient, especially if you're working inpatient settings. There's usually not a chair around. It really will be. You will gain so much more from going to get a chair assisting with that patient. You get a lot more from that conversation, and it's kind of hovering and standing above them. Okay, you can tell them how long you have. Okay, so you may only have 10 minutes, so but you'll say, you know, I only have 10 minutes, but this is a really important conversation that I want you to have the time for us to speak together. So if we need more time, we can arrange that. Okay, So again, it's making them know that you know you're not rushing them. And if they need more time, you can give it just some just at a later date. Then this next one, which is Listen, uh, listen and use opportunities. That's what somebody said before. And hopefully I've given you some examples of the types of opportunities that you can use, and hopefully, actually, there's a lot more than you thought you might have. So patients say all the time will I get better? Will this happen again or they can use it doesn't even have to be questioned. Sometimes they use statements like, I don't know why this treatment doesn't work. All of these things are little nuggets that you can pick up on and use to kind of progress. The conversation on Okay, the next one about clarifying is that I think people say things all the time, which means very different things. Different people, you know, You hear when people are getting discharged, I'm not ready to go home yet. Um, I'll be ready to go home when I'm better. And, you know, can you tell me what you mean by better? Because some people will have wild expectations that, you know, they're never going to meet. And actually, your priority at that time is then to try and maybe recalibrate those a little bit. Um, or it could be something that you just not thought of that you didn't realize there was a problem for them. Um, and actually buy, eliciting it. Then you might be able to get them discharged a little bit faster. The same thing goes, you know, I don't want to be a burden. I said, What does what does being a burden look like to you? Because what we think is a burden may not be what somebody else is thinking. The next one is reflect on experiences to talk about the future. So I think people find it really hard to really envisage themselves in certain situations. And actually, you need to really use what's happened to them already to kind of transition them. So, um, I might ask things like, you know, if somebody's been in hospital quite a few times, What was it like the last time you came into hospital? What? What changed from when you came into hospital and when you left. So this idea that, you know, people think coming to hospital will make them better. Actually, if you've seen them come in quite a few times, and even after they have their nebulizers and their antibiotics, they're not significantly better. It's about getting them or hearing from them. What they think coming to hospital is actually giving them. And and then because of that, you can transition into you know what do you think about coming to hospital again if something similar were to happen? So this idea of using otherwise you're kind of just maybe saying a hypothetical situation that they don't quite connect the two dots. You're just helping them bridge for me to be. And my last one is really that you're there to guide the conversation, not necessary to deliver a lot of the information. So I always try and use my questions to get, whether it's the patient care or family to reach the conclusion that I want them to get, too, without really delivering it all myself. And I think this is useful because you end up using the language that they're comfortable using. But also you may find that you don't need to say the difficult things. You might just need to agree with them or agree with one of the options that they've given. You know, people might say, You know, I think that this might be the end of the road in terms of my treatment, but I don't know, or I hope that they're able to offer me something else or something like that, and you can say I think it's really hard, but I think we might be looking at no more treatments or something. And you can use what they said. They've already given you the hard, hard bit. I've had families. Tell me, you know, we're really you know, I can't tell if the last few days means that they're dying or that he they can get better. And then you can just say I agree. I think that they may be dying, and then they've already kind of broach the subject for you. So again, try and use the the guide. Okay, so now we're looking at possible outputs of advanced care planning, so this might be a little bit more, um, exam focus. This is the stuff that make it may come up in an exam, So I know that there's at least one medical student out there. Um, so you've got advanced statements, advanced decisions to refuse treatments or sometimes called living wills, lasting power of attorney. And then things are very context specific treatment recommendations. So we'll go through each one and then we'll see how it all comes together at the end. So that statement. So this is something that really indicates somebody's future wishes. Okay? It's not legally binding document and how you should use it. So use it to get to know your patients really, before they even come in. And while they're there, if they've got an advanced statement, it just means that you know a little bit more about them. Um, and you should be taking this information into account if you ever have to make the best interest decision on their behalf if they if they don't have mental capacity. Okay, so the practical tips really about where to find advanced statements, A lot of places now will have, um, an electronic palliative care coordination system impacts. It's never actually called that in London. It used to be called Coordinate my care. It's now called, I Think The London Urgent care plan. In other places, you'll have different acronyms. Um, a lot of places are trying to integrate into the electronic healthcare record's. There might just be a button that you click on through your email or your system one or whatever system you use, so make sure you have access because a lot of them might need a specific log in and familiarize yourself with what's on there and what kind of information you can get and advanced decisions. So these are documents specifically stating treatment that that person does not want to have under very specific circumstances. Okay, it is legally binding. And for life sustaining treatments, it needs to be written down. It needs to be signed, it needs to be witnessed. And it needs to be clearly stated that those wishes still hold even though it may mean that they they die. So it needs to be clearly stated that they understand exactly what they're kind of saying that they don't want and the implications of not getting it. Okay, You know, people can't refuse general basic care. So things like hygiene offers or food and drink warmth shelter those or they can't refuse those. Okay, um and also, it's important to remember that treatment also includes any clinically assisted nutrition hydration. So your peg feeding your TPN feeding IV fluids, sub cut fluids. All of that is seen as medical treatment, so people can refuse those. Okay, how should it be used? So you need to be making sure that if somebody has one, that it's valid and applicable, and there is a checklist available, and I'll show you the document where you can find the checklist and you really can use it just to advocate for your patients, because what you find is that there's a lot of people who, despite it being there, may try and say, Well, it's not it's not applicable in this situation And but actually you've got something a legally binding document that gives you an indication of what the patient would have wanted to really use it to advocate. So the practical thing is, you should always make sure that you have a copy of it. Don't just take somebody's word for it and if needed, because it's the type of document that people will have generally shared with their healthcare professionals and may have discussed a little bit more in detail with the GP is somebody that you can call upon if you're in a hospital and you're not quite sure exactly what circumstances this person had made it, You know, With that in mind, you can talk to the GP and see if they've had any kind of further discussions with them. You know a lot of them you'll find that you have to be very, very clear in your words and you know people right? And if in a case of irreversible brain damage, I've seen that one, you think it's pretty clear this lady had kind of a post operative stroke and the argument from some of the teams involved in her care, Whether it's not irreversible, she still has a chance to improve. But it may take months, and they were arguing then that that a D. E r t was not applicable. And therefore we should be doing all of the stuff that she had kind of probably clearly not wanted, um, which included clinically assisted nutrition and hydration. And I think we managed to. We avoided a very big conflict with the clinical team because her stroke had actually meant that she was awake enough to take oral foods and fluids, and actually it was. She was able to take enough oral foods and fluids that they didn't think clinically she needed to have a peg or something else to assist. But I think if she did, we would have been a really difficult situation. Um and obviously you need to get more and more opinions and of course, this will never be left on you. You'd be involved in your consultant and things like that, but just to kind of be aware that just because somebody has an advanced decision doesn't always mean it's very clear cut in practice. The next one is, um okay, sorry. This next one. This is where you can find your little checklist again. If you just type in advance decisions to refuse treatment, a guide, you'll be able to get this document. And it kind of takes you through how you make sure that it's valid and applicable. Okay. So lasting power of attorney This again is a legally binding document that basically gives somebody the right the ability to speak on somebody else's behalf. They should still be acting in that person's best interest. So if you think that they're proxy, they're lasting power of attorney is not as a clinical team, you don't agree with the decision that's being made that can be escalated, Okay, legally escalated to the courts. Um, just a little note that a court appointed attorney or court appointed deputy has exactly the same rights as a lasting power of attorney, but they usually they will be appointed by a court after capacity is lost so people can make a lasting power of attorney. When they got capacity, they nominate the proxy, and that's fine. If somebody already has lost their capacity, it can be taken to the courts to get somebody nominated. But they've got a slightly different name. Is a court appointed deputy. Okay, how should you use it? You should always be making sure that's valid. Okay, so there's so many people who think they have it, but actually they have something for property and affairs, not health and welfare. So you need to be making sure it's health and welfare. If there is more than one attorney, you need to be checking on their documentation if they're able to act on their own, or if they have to together as a group two or more whoever how many attorneys are appointed. So the wording that's used on the form is jointly have to act together, or several e, which means they can eat at individually. And you have to make sure, especially if it's something about life sustaining treatment that that was included as a tick box. When they appointed, they're lasting power of attorney because you can appoint somebody, but still not give them the right or the ability to make life sustaining treatment decisions. Okay, so if that's coming into what you need to be making sure that that they are actually eligible and valid to do that okay, again practical tips as to see the document, you're not going to be able to check that it's valid without seeing the document. Um, if you have any suspicions, I've had people who say I am the lasting power of attorney. I can't get the document because it's in another country. Oh, it's in a safety place that I can't get to. You can check with the office of the public guardian that is registered. It does take, it says on their website. It may take like five working days or something to get back to you. So if it's a decision that can wait, you should be doing that. If it's a decision that can't wait, you obviously have to talk to your consultants and seniors and see how you're gonna kind of progress and kind of how much weight you're going to give you. This other person's decision making Um, but actually, you can check if it's registered if they've got somebody. And if there's no lasting power of attorney, people sometimes get families get very upset because they think that they're not going to be involved. And that's not true. I would reassure families that they'll still be included in the discussions and make and when you're making decisions. And actually, I sometimes tell people, you know it's a piece of paper in practice, it doesn't make a whole lot of difference, because usually the decisions of the team and the family, usually most of the time kind of kind of aligned the thing you have to be careful of. If people have an advanced directive and the lasting power of attorney, whichever one was made after or later takes precedence over the other. Okay, so if they have signed an A D E r t, um, that's meant to be for life sustaining decisions. If they then go on to make a lasting power of attorney and give their attorney the ability to make decisions about life sustaining treatment, the LP a trumps the a D E. R t. Okay, of course, you're not just going to ignore the a d E r T because that's a clear indication of what their wishes would have been. But legally, the LP A is taking precedence and saying the other way around. Okay, so you have to find out which one's the most recent and context specific documents are guys to future clinicians about specific context of these are things like DNA, CPR, respect documents. They're not legally binding there just to be used by you to make a decision going forward. Uh, communication across settings is key. So again, if you're in hospital, you need to be making sure these documents get to the GP in primary care and ideally, giving people a paper copy to go home with. And you should really know the laws around DNA CPR discussions. And I believe that you're getting a topic on DNA CPR. So I'm not going to go into that too much now. Okay? And again, it's about making a decision at a specific time in the future. So having a d and for a specific thing. So, DNA CPR, as you all know, does not guide whether you're going to start antibiotics or somebody at the end stage of the terminal condition. It really is just about giving CPR. Um, in the same way that you know, it's not legally binding. So somebody's chokes and has a respiratory arrest. You know, you may still choose to do recess and CPR if even if the d. N a. C p. R is in place just because, you know, it might be that they're actually not at the real end of their disease trajectory. And you still think that they've got a decent chance of making a recovery because you caught it just in time. And, you know, if you remove that bit of steak, you know you're going to bring them around quite quickly with very little impairment. So just remember that these things are guides, but they're not kind of you know you're not. It's not legally binding. Document. Okay, so this is just a print out of the respect document. I'm sure this is getting rolled out in lots of different places, so you may have seen it as you can see the first bit about what their understanding is saying things that you're having in your conversations. That's what matters to me. Thinking of it as a spectrum from living as long as possible to focusing on quality of life, this idea of what that means in clinical practice. And then there's a bit at the end about DNA CPR. Okay, sorry. I'm shuffling forward now a little bit quicker, because I realized that we're heading towards half past seven. So bringing it all together. So this is how and when you're going to be using your those those documents that we've just been talking about. So you've got a patient who likes capacity to make a specific decision. So again, it's not in the scope of this presentation to talk about how you're assessing capacity. You already established that you've done that all according to the mental capacity, yet they don't have capacity. So do they have an A, D E, R T or an LP A or a court appointed guardian? Okay, so if they do, you need to establish which one is the most recent you need to be establishing If it's valid. If it's applicable, and if all those things are yes, then the person's wishes should be respected. Okay, If it's a no, then does the patient have family or friends that you can consult with. If they do, you're making the best interest decision. And again there are a whole document out there about the best interest decision process and how you should be making the best interest decision. And we don't have scope here to do that. But you will be consulting the family and that decision. And at that point, that's when you use any of your advanced statements or context specific plans to support your decision. Okay? And no, it's exactly the same. Except you should be considering referral to an income so independent mental capacity advocate. So, um, these two are the same in terms of using your advanced statements to support your decisions. Okay, so the last this is my last slide. It's another quote from one of the parts of care consultant in London, and it's really strong, but I think it's served to me. A really powerful message of why I'm having these conversations is really important. Okay, so it's morally wrong to waste the dying person's time. So it's really important for us to know what matters to people and how they want to be spending their time and what their priorities are because, you know, they're never gonna have that time again. And this is your one chance to get it right. So I know it's really hard hitting, but it really does make you think so. Thank you very much. I'm going to exit out my presentation and then come to questions. Thank you for that. That was really interesting. I have that. I have about 10 minutes. Yeah. Does anybody have any questions? I'm just having a look at, um, the chat to see if there's anything on there. Great. And it's so nice to see you got paramedics. We've got all sorts of advanced nurse practitioners and everything. This is great. No questions, though. I suppose I had a question which is just about how you manage with talking to patients about kind of the future and prognosis and things when they could have such a wide range of diagnoses. And if you're not very familiar with, you know, if they're having quite specific on oncological care or something like that. So I think, um, being uncertain is fine. And being truthful about that is fine. Um, that's when I would say, you know, if it's a specific oncology treatment, especially with immunotherapy. Now it's so hard sometimes I'd say deficient. You know, what has the oncologist said? Um, and they may or may not have had that conversation before, and I might offer because actually, it might be hard for that patient to talk to the oncologist and not quite understand what the oncologist is saying. And sometimes the oncologist might not be as candid when they're talking directly to the patient. So I might offer and say, You know, I can't answer this straight now, but I can definitely ask your specialist. You know, it doesn't have to be in college or anything, Um, what their thoughts are, and then I can come back to you. Um and I think actually, that way you probably would get more truthful answer from the clinician. Yeah, definitely. Yeah, thank you. I think the other thing about timing is, you know, it's always hard to say, and generally we try and think in terms of maybe years, months, weeks, days and not be able to kind of put a specific number on things, and then I might deliver it that way. Although I have to say I have used that. That's that's what we advocate doing. And you still say weeks, weeks, two months. And then you'll get somebody coming back saying you told me it was two weeks. I never said that. So people hear what they want to hear. Yeah, a quick look. A few more people. Lovely. Great to see people working alongside hospice is already think you've seen a um yes. Somebody asking about a copy of the presentation. I don't know if that is something that can be shared. Yes. So we will put up a link, um, to the presentation afterwards, That sort of recorded through the through the platform. So we'll send out a link if people want to watch it back at a later date. Okay, Hopefully that's yeah. Yeah. Okay. Well, should we leave it there? Thank you so much. That was really helpful. And I'm going to post in the chat the sign up for next week's event for anybody who's interested. So next week, we've got, um, an I. T. U consultant from King's college in London, talking about the role of palliative care in I t U. So it should be really interesting, and yeah, I hope Everybody has a nice rest of their evening. Thank you so much for joining after hours. Yes, thanks very much. Bye bye.