| Continuity of care Shared care of patients—who’s role is it? Time pressures/workloads Challenges of best timing of ACP discussions within disease trajectories Need for ACP/DNACPR discussions in acute environments often by teams not familiar with patients
| Proactively seeking out opportunities in community by GPs and nursing teams (eg, posthospital discharge27) Proactive use of tools in hospital and community (such as the SPICT tool48) to identify patients who would benefit from ACP discussions, followed by targeted outreach by familiar medical/nursing team Improving electronic communication between primary and secondary care teams regarding existing ACP/DNACPR discussions: use of electronic Palliative Care Summaries (such as the eKIS44 Empowering and encouraging all clinical staff to develop communication skills and mandatory training to encompass ACP/DNACPR discussions. Development of specific ACP nursing roles to lead and educate rotating staff within individual wards/units/GP practices (‘Link’ nurse roles in hospital wards to interact with palliative care teams where needed for advice, GP practice ‘ACP outreach’ roles to monitor patients requiring ACP follow-up at regular practice meetings)
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| Time pressures, communication challenges Difficulty knowing who to involve, where, when to discuss Family not always available when discussions take place
| Development of support roles in acute settings following ACP discussions and to identify follow-up conversations needed Integration of ACP screening questions at specialist outpatient clinic (eg, chronic disease/oncology) where frequently patients have established trusted relationships. Initiating ACP discussions can be enabling for patients/families, especially in diseases such as MND29 Incorporation of ‘What (and who) matters to me’ section in to any ACP created with helpful descriptions such as ‘Would ‘always/prefer/ not wish’…. Mr/Mrs X, Tel…. to be involved in decisions about my care’
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When? Timing of discussion needs to be individualised and early in illness Where? Not during acute admissions, dislike of busy wards (vulnerability impacts on decision making)
| Pressure to discuss (legal) Opportunities and time is limited Space and environment limited Challenges of PFC expectations/fear of difficult conversations
| Development of national processes to improve consistent awareness of good practice approach to such discussions (eg, http://www.ReSPECTprocess.org.uk)12 and incorporation of these conversations in to routine ACP planning Prioritising person-centred quiet areas in workplaces/wards for discussions Routine patient ACP information gathering on ALL admissions to hospital: Checking electronic information summaries,44 legal (welfare/financial/combined) guardian/power of attorney, next of kin, ‘What/Who matters to me’?, advance statement/living will to aid in ACP discussions
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Delivery: Individualised, honest, straightforward, empathetic language. Avoiding vague terms. Consider level of education/literacy. Include discussion about QOL
| Basic communication skills training not always sufficient Often seen as the ‘doctor/consultant’s role’ Busier, larger acute medical takes with multimorbid patients.
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