Background The Respecting Patient Choices team has been doing advance care planning since 2002. We encourage people to nominate a substitute decision maker (SDM) and document their health care wishes on a ‘Statement of Choices’ (SOC). This document has evolved and now includes four components to ensure that the written plans are understood and appropriately acted upon by doctors. They are: to record a person's wishes about future medical treatment based on their goals, values and beliefs. to record this information in a language that doctors would recognise and could act upon. be easy to fill in. to provide prompts for people facilitating the ACP conversation. Aim To evaluate the evolution of the SOC. Methods A retrospective audit of SOC completed in 2010. Results Most people (70%) choose to nominate a SDM and complete a SOC. People generally nominate a family member as their SDM and the majority (>90%) indicate on their SOC that they ‘would not want CPR even if the doctors think it could be beneficial’ and ‘do not want life prolonging treatment (LPT) at all’. 25% provided guidance on what would be an ‘acceptable outcome’. The SOC is recognised by the doctors and is acted upon. Conclusions ▶ Austin Health has devised a SOC form that enables people to record their medical treatment preferences especially in relation to CPR and LPT. ▶ The SOC is being further evolved for specific chronic conditions (eg, dialysis).
The Australian Government funds personal and clinical support to the frail/unwell elderly to support them to live at home. These Home Care Package (HCP) clients have a case manager (CM) who, with the client and family, coordinates the client's support services. Advance Care Planning (ACP) is important to these clients. The CMs can either assist the client with ACP ("Facilitator Model") or refer the client to a separate ACP service ("Referral Model").
Aim
To test the Referral and Facilitator models in a Randomised Controlled Trial (RCT).
Methods
CMs, who were randomised to the Referral or Facilitator models, were trained for their model and implemented to their 25 clients. The trial evaluation included: Assessing CM knowledge, attitudes and practice regarding ACP Auditing client's files to measure ACP documentation quantity/quality. Interviews/focus groups with CMs to explore perspectives/experiences/attitudes re ACP.
Result
Randomisation of 35 CMs, representing 800 clients. Training improved confidence (17 CMs pre, 32 CMs post felt confident) and comfort (22 pre, 33 post felt comfortable) in discussing ACP and improved knowledge (31% pre to 80% post got 6 or 7/7 correct answers). Barriers to ACP completion include insufficient time, CM confidence and experience, client ability to access services, and engagement with GPs. Full audit data analysis will be completed by April 2015 and presented at the ACPEL conference.
Discussion
The CM knowledge of the client/family/GP/context supports the Facilitator model, whereas the expertise of the ACP service supports the Referral model. To be discussed in full at conference.
Background In March 2011, Respecting Patient Choices at Austin Health established a Volunteers Program to provide education to community groups about Advance Care Planning (ACP). Commencing with 18 Frequently Asked Questions (FAQs), this expanded to 92. Aim To review the need for, the benefits and implications of expanded FAQs. Methods The FAQs at programme commencement were compared with the FAQs by December 2012. Volunteers were interviewed regarding the FAQ development. Results The expansion of the FAQs was driven by consumer demand at Information Sessions; 18 broad questions were not satisfactory. The 92 questions (not all asked at each session) could be grouped into themes. Themes included: Role of the GP; Conflict; Competency; Legal Issues; Organ Donation; ACP in Critical situations; Euthanasia; Dying with Dignity, Religion and ACP. The attendee feedback regarding the sessions and questions was very positive; 94.2% of 309 attendees agreed/strongly agreed that their questions were answered; 96.8% agreed/strongly agreed that the presentation increased their ACP knowledge. Discussion The FAQs were expanded to meet community expectations about information provided at the sessions. The benefit of expanding this list was that new Volunteers would be aware of the type of questions that would be asked, and that consistent answers could be provided. The implication is that Volunteers providing information to community groups need to have detailed knowledge of the entire ACP process. Conclusion Expanded FAQs required very specific responses, provided greater satisfaction and meant that Volunteers needed high level knowledge of the ACP process.
There are only a limited number of studies on the content and completion of Physician Orders for Life Sustaining Treatment (POLST) forms. No study has specifically examined the use of POLST forms within an acute hospital setting. We audited 1096 randomly selected Resuscitation Plans, a locally developed form of POLST, completed in a university hospital during 2011. Matching patient identification numbers resulted in 789 individual patients (49.7% Male; 64% aged 75+), of whom 187 had multiple plans during the audit period. The most recent plan for each patient was examined for content. Plans were most commonly completed by Registrars (539, 68.3%), and 99.7% of plans were signed. The majority of plans indicated orders for treatment limitation (608, 77.1%), and these patients were significantly older than patients with an order for full treatment (p=.001). Information on the decision making process was completed in 540 cases (68.4%). Of these, 63% had evidence that the patient/family had been involved in, or were informed of the decision. There was a significant association between limitation of treatment and evidence of family/patient involvement in the decision making process (p=.001). Forty-nine percent of patients with multiple plans had orders in the most recent plan for less-aggressive treatment, compared to the prior plan. A further 44% had no changes to treatment orders over consecutive plans. The use of POLST forms in an acute care environment is dynamic and complex. Evidence of patient/family involvement in the decision making process should increase as local advance care planning programs progress.
Objective: To evaluate the effects on temperature and outcome at hospital discharge of a pre-hospital rapid infusion of large volume, ice-cold intravenous Hartmann's solution in patients with out-of-hospital cardiac arrest and an initial cardiac rhythm of asystole or pulseless electrical activity. Design: Prospective, randomized, controlled clinical trial. Setting: Pre-hospital emergency medical service and 12 critical care units in Melbourne, Australia. Patients: One hundred and sixty three patients who had been resuscitated from cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity. Interventions: Patients were randomized to either pre-hospital cooling using a rapid infusion of up to two litres ice-cold Hartmann's solution (82 patients) or cooling after hospital admission (81 patients). The planned duration of therapeutic hypothermia (32°C–34°C) in both groups was 24 hrs. Measurements and Main Results: Patients allocated to pre-hospital cooling received a median of 1500 ml of ice-cold fluid. This resulted in a mean decrease in core temperature of 1.4°C compared with 0.2°C in hospital cooled patients (p < .001). The time to therapeutic hypothermia (<34°C) was 3.2 hrs in the pre-hospital cooled group compared with 4.8 hrs in the hospital cooled group (p = .0328). Both groups received a mean of 15 hrs cooling in the hospital and only 7 patients in each group were cooled for 24 hrs. Overall, there was no difference in outcomes at hospital discharge with favorable outcome (discharge from hospital to home or rehabilitation) in 10 of 82 (12%) in the pre-hospital cooled patients, compared with 7 of 81 (9%) in the hospital cooled patients (p = .50). In the patients with a cardiac cause of the arrest, 8 of 47 patients (17%) who received pre-hospital cooling had a favorable outcome at hospital discharge compared with 3 of 43 (7%) in the hospital cooled group (p = .146). Conclusions: In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity, pre-hospital cooling using a rapid infusion of large-volume, ice cold intravenous Hartmann's solution decreases core temperature at hospital arrival and decreases the time to therapeutic hypothermia. In patients with a cardiac cause of the arrest, this treatment may increase the rate of favorable outcome at hospital discharge. Further larger studies should evaluate the effects of pre-hospital cooling when the initial cardiac rhythm is asystole or pulseless electrical activity, particularly in patients with a cardiac cause of the arrest.
A 74-year-old man with myxedema and hypothermia had increased activities in plasma of creatine kinase (CK; EC 2.7.3.2), aspartate aminotransferase (AST; EC 2.6.1.1), and lactate dehydrogenase (LD; EC 1.1.1.27) and increased proportions of CK-MB (up to 20% of total CK) and LD1 isoenzymes, but no clinical or investigational evidence of associated myocardial infarction. This case illustrates that plasma enzyme activity and isoenzyme profiles in such clinical settings should be interpreted with caution, because increases in CK-MB and LD1 may relate to myxedema coma or hypothermia (or both) rather than to myocardial infarction.
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