Background Advance care planning (ACP) is an integral part in the management of end stage heart failure (HF). This is often poorly done in medical wards. To improve this aspect of care, we focussed on discussions with patients and their families regarding prognosis and ceiling of care, explored patients‘ wishes for end of life care including hospital admission avoidance, liaised with palliative care team on pre-emptive medications for treatment in community and communicated with GPs on advance care management. This study presents the outcomes of these interventions.
Methods End stage HF was defined as patients with severe refractory symptoms (New York Heart Association class 3 and 4) despite optimal medical treatment. This diagnosis was confirmed by echocardiogram and clinical assessment by HF team. The following interventions were used to improve ACP:
training at departmental induction meeting to identify end stage HF patients;
medical teams encouraged to initiate ACP discussions;
poster to remind junior doctors of the relevant information to include in discharge summaries to GP
Data were extracted from medical records and discharge summaries to assess the impact of these interventions.
Results Data were collected from 63 patients between August 2016 and March 2017. Discussions on prognosis and ceiling of care improved from 8.6% to 25.0% and 14.3% to 28.5% respectively. There was better communication to GPs on inpatient (2.8% to 21.4%) and community (8.6% to 21.4%) palliative management. Pre-emptive medication prescribing increased from 8.6% to 14.3%. There was discrepancy in ACP documentation in medical records vs discharge summaries (38.1 vs 25.0%).
Conclusions Despite improvement in ACP and its communication to primary care, significant gaps still exist. This study highlights the challenges in implementing this aspect of care in acute medical setting. Innovative strategies at trust organisational level are needed to deliver this care more effectively.
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