Impact of COVID-19 on Advance Care Planning for older patients with frailty
Caroline Gale is an Advanced Nurse Practitioner for Frailty at Frimley Park Hospital. She recently completed dissertation on Advance Care Planning as part fulfilment of MSc Advanced Clinical Practice at Kings University London. She tweets @carolinedeane17
When COVID-19 emerged in the UK in March 2020, with potential to overwhelm health care provision, NICE responded with the COVID-19 rapid guideline: critical care in adults (159). This guideline directed clinicians in the hospital setting to use the Rockwood Clinical Frailty Scale (CFS) to triage patients on arrival for their suitability for escalation of care.
Advance Care Planning (ACP) has been internationally recognised as an effective, compassionate tool to support choice, avoid ineffective and invasive interventions, and reduce hospital admissions. NHS and DofH guidelines have promoted ACP since 2008. The NHS long term plan emphasises the importance of “what matters to me”, and we are all familiar with the phrase “no decision about me without me”.
I was working in the ED environment in March 2020, as an advanced frailty practitioner, and given the task of providing some education to my ED colleagues on the concept and implementation of a CFS assessment on the patient’s arrival in the department. Our team had already been working towards the introduction of CFS on the ED electronic patient records. We met with the medical and nursing teams at handovers to provide short teaching sessions, supported by our “Rockwood” mouse mats.
Older patients with frailty arriving in ED were mercifully few and far between, but the inflexibility of NICE rapid guideline 159 was evident at the outset. ACP has always been about promoting choice, preserving dignity and the delivery of patient-centred care. I was in the process of researching ACP for patients with frailty for my MSc dissertation, but nothing in my research had prepared me for a process of ACP which overruled individuality, challenged clinical autonomy and used the CFS as a potential rationing tool for critical care.
I am thankful for the efforts of the BMA and RCN in challenging the initial guideline, which resulted in several amendments to recommendations throughout March and April, and which clarified that the CFS was to be used, as usual, as part of a holistic assessment in the context of specialist advice.
Looking at the positives, the new guidelines have moved ACP up the agenda for ED clinicians, and older patients presenting with a frailty syndrome are more likely now to be asked “what matters to you?” and for a discussion about resuscitation to be considered.
The background of COVID-19 has brought the subject of death and dying to the fore, in a population of both patients and clinicians previously reluctant to discuss this. We need to use this as an opportunity to develop ACP as a concept amongst our frail older population to promote honest open conversations about goals of care and what patients really want.
What emerged from my own work, was a lack of consistency and standardisation of documentation of ACP, which means that even when resuscitation is discussed, other related aspects of ACP were not included as part of the conversation.
The ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) document offers a framework for recording conversations between patient, carers and clinician, to note their wishes for care, and agreed ceilings of care. Its use has been validated by the Resuscitation Council. Introducing this tool represents a standardised way of empowering our patients to discuss the way their care is delivered, to reduce futile interventions, and to manage admissions to our acute hospitals. ReSPECT is equally valid in the community and hospital settings, providing a transferrable record of decisions about the patients’ resuscitation status and agreed care goals.
None of us want to face the prospect of a second wave, but it is now an unavoidable reality. It will benefit our patients, their families, and our health services, if we prepare by asking about how, and where our frail older patients would like to be cared for, document this in a robust way, and deliver the right care in the right place? This is an opportunity to drive positive change from a challenging situation that should be grasped, taking into account the lessons learned from our experiences earlier in the year.