A Different Approach to Advance & Future Care Planning DNACPR Conversations for Older People Living with Frailty – A Quality Improvement Project for NHS Wales’ Advance & Future Care Planning Strategy Group

Author Details

Laura Ellis-Lane  B.Sc. Physiotherapy; M.Sc. Advanced Clinical Practice; PGC Falls and Osteoporosis; Professional Doctorate Candidate. Consultant Therapist – Frailty / Older Peoples’ Rehabilitation , Care of the Elderly – East Integrated Health Community – Betsi Cadwaladr University Health Board, Wales, United Kingdom

Dr. Wendy Wilkinson  B.H.Sc. Occupational Therapy; M.H.Sc Occupational Therapy; Professional Doctorate; NICE Scholar. Consultant Therapist – Frailty / Older Peoples’ Rehabilitation Care of the Elderly – East Integrated Health Community – Betsi Cadwaladr University Health Board, Wales, United Kingdom

 

Introduction:

Traditionally, conversations relating to advance and future care planning (AFCP) and do not attempt resuscitation (DNACPR) decisions have been considered the responsibility of medical doctors. Over the past 10 years, the profile of the NHS workforce has changed. Key changes have seen a greater diversity in allied health professionals (AHP) and nurses stepping into senior clinical / consultant roles, responsible for the care of older people. These professions are required to hold advanced clinical practice (ACP) qualifications, clinical competencies and experience, often equivalent to their medical consultant counterparts. They will nowadays often be asked to get involved in senior reviews such as mortality reviews and discussions with coroners.

 

Background:

In 2022, two consultant therapists were recruited to Betsi Cadwalladr University Health Board in North Wales (UK). These roles were designed to provide a pragmatic approach to managing frailty and older peoples’ rehabilitation, in line with Welsh Government’s Prudent Healthcare Principles (2016)[1]. The daily work of these consultant therapists reflects many of the roles, values and responsibilities to those of a consultant geriatrician on a rehabilitation ward in the community hospitals, including being named senior responsible clinician (SRC). One of the tasks of the clinical role in dealing with seriously unwell patients with palliative needs and frailty, is to lead on Advance & Future Care planning and DNACPR discussions, sensitively eliciting the views of patients and those close to them, and fulfilling the duty to consult.

In the last review of the All Wales DNACPR Policy (2022)[2], medical and nursing consultants were both named as being eligible to sign section 6 of the All Wales DNACPR form if they fulfil the role of an SRC in their organisation, but the policy was less clear and specific about consultant AHPs. Of course, not all AHP and nursing consultants work in a role where they accept the level of responsibility expected of an SRC, and of course not all work with frailty and in settings with a lot of palliative and end of life care. But there are many very senior and experienced AHPs, working for instance as Occupational Therapists, Physiotherapists or Paramedics and with training in palliative and end of life care, for whom these sorts of conversations happen weekly, if not daily.

In the national all Wales DNACPR policy review scheduled for 2024, AHP consultants (with equivalent clinical knowledge, skills and competencies), will become eligible to discuss and endorse DNACPR decisions alongside their medical and nursing consultant colleagues. This has been recommended following a series of stakeholder engagement and quality assurance activities to ensure that this amendment is underpinned as being of sound quality, safety and acceptability by older people and those with palliative care needs nearing the end of life. This change is also supported by the Older Peoples’ Commissioner for Wales[3] as well as the Ruth Crowder the Chief Allied Health Professions Adviser for Wales.

 

Methods and Results:

In 2023/24, the following activities were undertaken in partnership with the All Wales DNACPR group.

  • 16 week pilot (May – August 2023) analysing DNACPR conversations undertaken and documented by consultant therapists as per All Wales Policy. 100% were countersigned by Consultant Physician / General Practitioners. The DNACPR discussions were discussed with family on 70% of occasions. Where there was no discussion with family, this was at the specific request of the older person.
  • Clinical audit of consultant therapists’ DNACPR forms: achieved 100% compliance using the All Wales DNACPR Audit tool. The need for ward administration processes to ensure the forms were shared with Primary Care and Welsh Ambulance Service Trust (WAST) colleagues was highlighted as a result of the audit.
  • Qualitative feedback obtained from older people reflected a preference for having clear plans in place (i.e. “Thank you, I wouldn’t want to be worse than I am now”).
  • Qualitative feedback from local Multi-Disciplinary Team (MDT) members reflected a recognition that the consultant therapists demonstrated equivalent level of compassion, knowledge, skill and competence in holding DNACPR discussion (i.e. “Your communication with families is clear, confident, reassuring and empathetic”).
  • Benchmarking with All Wales Consultant Nurse and UK-wide Allied Health Professional (AHP) Forums highlighted that 60% of respondents engaged in end of life care and DNACPR conversations reflecting the most common settings for AHP and Nurse Consultant roles being found in emergency care (Emergency Department & Welsh Ambulance Service Trust), frailty and primary care. 30% of respondents felt that DNACPR conversations were not within their scope of practice, which may reflect that they are less likely to work with people who are considered clinically vulnerable or ‘sick enough to die’.

Conclusion:

We have seen during the pandemic and in the wider UK news, that older people and those close to them have expressed concern over DNACPR decisions being made prematurely, without discussion with the individual, and fears of a ‘blanket approach’. This project demonstrated that good discussions around end of life care are already happening and can be positive, individualised and with better communication and recording, and that AHPs can be an important part of improving and also overseeing this process, in work settings where they fulfil the criteria for such a role. They can enable older people to have a clear and timely voice in their future care planning, helping them to feel that they have been listened to.

 

References:

[1] Welsh Government  Securing health and well-being for future generations in Wales – a report  Securing-health-and-well-being-for-future-generations.pdf (gov.wales) [accessed 12/03/2024]

[2] All Wales DNACPR policy, NHS Wales Executive DNACPR – NHS Wales Executive [accessed 12/03/2024]

[3] Older People’s Commissioner for Wales – resources  Who can I approach to learn more about DNACPR? – Older People’s Commissioner for Wales [accessed 12/03/2024]

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