Advance care plan (ACP) for patients with multiple co-morbidities

Dr. Catherine Clelland (biography and disclosures)

What I did before

As patients with multiple co-morbidities age and their medical conditions become more debilitated, they face significant challenges in their day to day living.  Over my 25 years in full service family practice, I would try to manage their multiple medical conditions balancing the various clinical practice guideline recommendations against the individual patient needs and wishes.  Unfortunately, the discussion of advance care planning was time consuming and often only dealt specifically with the patient’s feelings about “code status”.  Often this only came once the patient had experienced a significant episode of decompensation (a sentinel event) that resulted in a trip to the ER or even hospitalization.  While I was aware of the “No Cardiopulmonary Resuscitation” form and the BC Palliative Care Benefits Program application, I was not aware of other tools to assist me with this discussion.  Like many physicians, I thought palliative care and end of life discussions were appropriate primarily for cancer patients.

What changed my practice?

In 2007, the GP Services Committee developed the Complex Care Planning fee (14033) to encourage Family Physicians to spend time with patients with multiple co-morbidities and develop a plan for their management.  At this planning visit, the FP discusses a patient’s wishes and desires for their future care, including end-of-life care and which life-prolonging medical interventions they might wish to have or refuse if they become incapable of deciding later.  An advance care plan (ACP) is developed with the patient that can then be reviewed on a regular basis and when their medical status changes.   Subsequent to this, the GPSC developed the Palliative Planning fee (14063) to compensate Family Physicians for developing a palliative care plan more specifically to address needs and wishes when a patient is felt to be in the last 6 months of life.  Both of these initiatives open the ability to provide follow-up medical management by telephone or 2 way e-mail.  FPs are also encouraged to conference with allied health professionals for the management of these patients and details of all the GPSC incentives can be found at http://gpscbc.ca/billing-guide-fees.  Specialists are not eligible to access the GPSC billing incentives, but the Specialist Services Committee is working on a similar incentive to encourage end of life planning.

More recently, the Practice Support Program has begun the “End-of-Life” PSP Module to encourage the earlier identification with the use of the “Surprise Question” (Would I be surprised if this patient were to die in the next 6 – 12 months?) and the development of a registry within the FP practice of patients who would benefit from a palliative approach to care.  It encourages the use of the “My voice” tool that was initially developed by the Fraser health Authority and is now the provincial Advance Care Planning tool.   This module also supports the integration of care (FP, Specialist, H&CC, Palliative Care and other supportive services) around the patient and family to encourage medically appropriate care and services at the end of life in the location preferred by most patients – their home.  More information can be found at http://gpscbc.ca/psp/learning.

What I do now

When caring for patients with multiple co-morbidities and/or cancer, I use the “Surprise Question” to develop a registry of patients who would benefit from a palliative approach to care so that I can identify and assess their symptoms and begin talking with them about their health status and goals of care at an earlier stage.  I use the “My Voice” tool and feel more comfortable asking them about their wishes in approaching this discussion.  Patients and their families have reported back that this reassures them that I am interested in their point of view and that they have confidence their wishes are going to be honoured.  Many are actually relieved that the topic has been raised,

Even if my answer to the surprise question would indicate the patient is not in the last 6 – 12 months of life, I am able to start the advance care planning conversation with patients when they are well.  At this stage, they are likely more able to make decisions about what they would agree to, or not, if in the future they are not able to make a decision for themselves.   I am also able to better access appropriate services to support them in their home through better coordination of care with my specialist colleagues as well as in the Home and Community Care program.  I feel I am able to provide better care for my patient and their family, as they progress in this final stage of their chronic disease management.

Resources

www.gpscbc.ca – All GPSC initiatives for billing and PSP modules can be found linked at this site.

http://www.bcmj.org/print/4158  – BCMA blog with links to other tools to support Advance Care Planning

https://www.bcma.org/news/advance-directives

www.health.gov.bc.ca/library/publications/year/2011/health-care-providers’-guide-to-consent-to-health-care.pdf  – BC Government Healthcare Providers guide to Consent

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Advance care plan (ACP) for patients with multiple co-morbidities

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