‘Just in Case’ Action Plans (Palliative & End-of-Life Care) Information & “How To” Guide Background There are gaps in palliative care services locally, both in and out of office hours. General Practices manage a significant volume of patients who are not under hospice. When a sudden change in a palliative patient’s condition occurs, accessing appropriate care can be difficult which in turn leads to more distress and suffering, and often unnecessary hospital admissions. Over the last two years (July 2017 - June 2019) there were 812 acute palliative admissions to Tauranga Emergency Department from the BOP (528 from WBOP). Of these admissions just 18% were referred by a GP and 74% were self (or family) referred. The majority of presentations took place during working hours, were non-cancer related and involved a steep increase in volumes from the age of 69 years. The demand for acute palliative care is expected to increase by 51% over 20 years as population growth increases, especially of the older adult (Ministry of Health, 2017). According to recent data, dementia represents the highest overall proportion of deaths in the Bay of Plenty (28.4%), and is the highest trajectory group for NZ Europeans and other Europeans. For Maori, cancer represents the most deaths (29.9%), for Pacific peoples the Need and Maximum Needs group (other palliative conditions including younger disability groups) at 33.4%, for Asian and MELAA, cancer, at 29.4%. Seventy-one per cent (71%) of all deaths have both public hospital and ED events in the last year of life (Trajectories Project, 2015).
Service description This initiative enables inter-provider support to be available to palliative care patients in the community. General Practice teams are invited to complete Action Plans with prescriptions for their palliative patients. Funding will be provided for each plan that is submitted and shared. These plans would enable other providers such as St John to respond to the patient when concerns arise, follow the plan and administer medications. The episode of care may involve end-of-life care, an exacerbation of a chronic condition, or an assessment towards a reversible cause. The plans would enable patients to be managed at home (or care facility) whenever possible and appropriate. If further assessment or treatment were indicated, a doctor’s assessment may be necessary. Whether this was through the General Practice team, Accident & Healthcare or the Emergency Department, consideration would be made for the most appropriate option. A discussion with the GP whenever possible would assist St John personnel in making this decision. The Action Plan would be supported by good conversations taking place with the patient/ family and whanau. Listening to the patient’s wishes, discussing realities, and writing a plan which reflects both is likely to improve the experience of care when a change occurs. The Serious Illness Conversation guide is a useful tool to support this (see resources).
WBOP PHO, RM, December 2019