Flashcards in Care Planning Deck (20)
What is a CGA - comprehensive geriatric assessment
A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological, and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up.
Carrying out CGAs prevents unnecessary deaths and institutionalisations.
What does a CGA (comprehensive geriatric assessment) involve?
CGA comprises multiple domains of assessment including
• Medical assessment
1. Problem list (continence, sensory impairment, musculoskeletal problems especially gait and balance, lying and standing BP)
4. Nutritional and skin assessment
• Mental Health symptoms: Mood, cognitive impairment
• Functional abilities and living environment – ADL’s, gait and balance, technology use, sensory loss (how are they coping with this?) and exercise and activity assessment
• Social support networks and financial situation, family, capacity and future plans
• Environmental assessment – home circumstances, accessible home, buzzers, stairs, life, toilet facilities, cooking, shopping heading and lighting.
Use this tool to create a problem list
From that list make a personalised plan
Which leads to an intervention
Following this is regular planned review of this list
What is advanced care planning?
Advanced care planning is a process of planning for the future so that a patient gets the care they want when they want it and where they want it as they age. This is not a one-off discussion but a process over time.
Who should care planning be done in?
Everyone, but realistically if you are treating a patient that you would not be surprised if they died in the next 12 months then it is important to have found out how the patient wants to be treated and how they don’t want to be treated in this time. Important to record a baseline whilst the patient is generally well. Must include both the patient and the next of kin in this discussion.
Describe the steps involved in formulating a care plan?
Steps - Think, Talk, Record, Discuss and Share (review) and use the Gold standard framework paperwork to find patient that need the discussion and use their form to start and guide the conversation.
1. Inform the patient and NOK that they are approaching the last months or that frailty and/or comorbidities mean that prognosis is not favourable.
2. Explore wishes of the patient e.g. life sustaining therapy at all costs or symptomatic control and hospital avoidance.
• What is important to you?
• Where would you like to be cared for in the future?
• What care do you not want to receive – advanced directive
• Who do you want to make decisions for you if you cannot make them yourself?
3. Share with friends and family that should know
How can information about a patients wishes be recorded legally and non legally?
Ways of recording this information
Lasting power of Attorney for health (legally binding)
Advance statement of wishes and preferences (not legally binding)
Advance directive to refuse treatment including DNAR or respect form (legally binding)
What is the process involved in following an advanced directive?
If a patient has an advance directive, then this procedure should be followed
1. Decide a person does not have capacity
2. Determine if they have advanced directive
3. Contact family, carers, GP etc.
4. Determine if advanced directive is applicable and valid. If not:
5. Make decision in patients’ best interests
6. Document why you haven't followed the advance directive
When do advanced directives become invalid?
Advanced directive are invalid when:
• Withdrawn whilst still had capacity
• Gave LPA authority to overrule
• Demonstrated they had clearly changed their mind
• Regained capacity
• Different treatment
• Grounds for which decision was based have changed
What is a ReSPECT form?
A ReSPECT form includes DNAR decisions and ceiling of care documentation (hospital, ITU, wad based, symptoms control, community therapy). This has replaced DNAR forms and can be used anywhere in the country and is the same for geriatrics as paediatrics. A ReSPECT form should be completed in discussion with the patient or someone with power of attorney. If a patient can’t make this decision themselves then health care professional can make it in their best interests.
Who is responsible for completing advanced care plans?
Advanced care plans are completed by GPs but if these wishes are first held in hospital then an Emergency health care plan can be made which then is used to communicate to the GP/Care home/Emergency services. The EHCP is only a temporary measure until the ACP is completed by the GP.
What is an escalation plan?
Escalation plan (Ceiling of Treatment)
This is a plan for what should be done if a patient were to fall ill and allow them to dictate what treatment and where they wanted to be treated. For example, if they were to develop an infection would they want treating at home, or in a hospital.
Examples of levels of hospital care to be considered
• Invasive ventilation
• IV antibiotics
What is poly-pharmacy
Poly-pharmacy can be defined as taking greater than 5 drugs at once although some say its 10. Its important to include herbal medications and illicit drugs taken in this drug count.
How does our body change as we age in relation to dealing with drugs?
Important to note than the pharmacokinetics (how the body digests) and pharmacodynamics (sensitivity) may be different in the geriatric patient. Especially as the percentage of fatty tissue vs muscle and fluid volume changes.
What should be considered when presented with a patient with poly-pharmacy?
When presented with polypharmacy there are multiple problems to consider
• Is the prescribing appropriate
• Are there any drug-drug interactions?
• Are there any intolerable or avoidable side effects?
• Toxicity – Toxbase is a good resource to deal with this, always consider QT prolongation.
• Withdrawal – consider antiepileptics, benzos, Parkinson’s meds, opioids, alcohol, nicotine, antidepressants, and antipsychotics.
What would constitute a poly-pharmacy that is appropriate?
1. All drugs are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient.
2. Therapeutic objectives are actually being achieved or there is a reasonable chance they will be achieved in the future.
3. Drug therapy has been optimised to minimise the risk of ADRs and (d) the patient is motivated and able to take all medicines as intended.
What would constitute a poly-pharmacy that is inappropriate?
Problematic: when one or more drugs are prescribed that are not or no longer needed, either because:
1. There is no evidence-based indication, the indication has expired, or the dose is unnecessarily high;
2. One or more medicines fail to achieve the therapeutic objectives they are intended to achieve.
3. One, or the combination of several drugs cause unacceptable adverse drug reactions (ADRs), or put the patient at an unacceptably high risk of such ADRs, or because (d) the patient is not willing or able to take one or more medicines as intended.
What tools can we used to help when making decisions about drugs in poly-pharmacy?
STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment). Basically a list of meds that you should consider stopping and starting in the elderly population.
What is anticholinergic burden?
Often important to review in the case of a confused patient. Lots of drugs that are not directly involved in the cholinergic molecule do have anticholinergic effects.
What is a prescribing cascade?
A prescribing cascade is when multiple medications are prescribed to treat the side effects of previous medications. This is more likely to happen if a symptoms is not as a result of an ADR.