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Advance Care Planning in Patients Referred to Hospital For View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Birmingham Research Portal University of Birmingham Advance care planning in patients referred to hospital for acute medical care Knight, Thomas; Malyon, Alexandra ; Fritz, Zoe ; Subbe, Chris; Cooksley, Timothy ; Holland, Mark; Lasserson, Dan DOI: 10.1016/j.eclinm.2019.12.005 License: Creative Commons: Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) Document Version Publisher's PDF, also known as Version of record Citation for published version (Harvard): Knight, T, Malyon, A, Fritz, Z, Subbe, C, Cooksley, T, Holland, M & Lasserson, D 2020, 'Advance care planning in patients referred to hospital for acute medical care: results of a national day of care survey', EClinicalMedicine, vol. 19, 100235. https://doi.org/10.1016/j.eclinm.2019.12.005 Link to publication on Research at Birmingham portal General rights Unless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or the copyright holders. 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Mar. 2020 EClinicalMedicine 19 (2020) 100235 Contents lists available at ScienceDirect EClinicalMedicine journal homepage: https://www.journals.elsevier.com/eclinicalmedicine Research Paper Advance care planning in patients referred to hospital for acute medical care: Results of a national day of care survey Thomas Knighta,*, Alexandra Malyonb, Zoe Fritzc, Chris Subbed, Tim Cooksleye, Mark Hollandf, Daniel Lassersona a Institute of Applied Health Research, University of Birmingham, United Kingdom b Cambridge University Hospital NHS Foundation Trust, United Kingdom c University of Cambridge, United Kingdom d School of Medical Sciences, Bangor University, United Kingdom e Manchester University NHS Foundation Trust, United Kingdom f School of Health and Social Care, University of Bolton, United Kingdom ARTICLE INFO ABSTRACT Article History: Background: Advance care planning (ACP) is a voluntary process of discussion about future care between an Received 1 July 2019 individual and their care provider. ACP is a key focus of national policy as a means to improve patient cen- Revised 24 November 2019 tered care at the end-of-life. Despite a wide held belief that ACP is beneficial, uptake is sporadic with consid- Accepted 4 December 2019 erable variation depending on age, ethnicity, location and disease group. Available online xxx Methods: This study looked to establish the prevalence of ACP on initial presentation to hospital with a medi- cal emergency within The Society for Acute Medicine Benchmarking Audit (SAMBA18). 123 acute hospitals Key words: from across the UK collected data during a day of care survey. The presence of ACP and the presence of ‘Do Advance care plan ’ Emergency admission Not Attempt Cardiopulmonary Resuscitation orders were recorded separately. Frailty Findings: Among 6072 patients presenting with an acute medical emergency, 290 patients (4.8%) had an ACP End-of-life care that was available for the admitting medical team. The prevalence of ACP increased incrementally with age, in patients less than 80 years old the prevalence was 2¢9% (95% CI 2¢7À3¢1) compared with 9¢5% (95% CI 9¢1À10¢0%) in patients aged over 80. In the patients aged over 90 the prevalence of ACP was 12¢6% (95% CI 9¢8À16¢0). ACP was present in 23¢3% (95% CI 21.8À24.8%) of patients admitted from institutional care com- pared with 3¢5% (95% CI 3¢3À3¢7) of patients admitted from home. The prevalence of ACP was 7.1% (95% CI 6¢6À7¢6) amongst patients re-admitted to the hospital within the previous 30 days. Interpretation: Very few patients have an ACP that is available to admitting medical teams during an unsched- uled hospital admission. Even among patients with advanced age, and who have recently been in hospital, the prevalence of available ACP remains low, in spite of national guidance. Further interventions are needed to ensure that patients’ wishes for care are known by providers of acute medical care. © 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/) 1. Introduction end-of-life care. Advance care planning (ACP) is advocated as a means to improve quality of care, increasing the likelihood of individuals More than half a million people die in the United Kingdom (UK) receiving care that reflects their preferences and is provided in their each year [1]. While some will die suddenly and unexpectedly the preferred environment, reducing the frequency of avoidable emer- majority of individuals will experience a period of chronic illness, gency admissions in the last months of life [3,4]. deteriorating health and live with increasing frailty before their ACP is defined as a process “enabling individuals to define goals death. In the UK, admission to hospital as an emergency is a promi- and preferences for future medical treatment and care, to discuss these nent feature of the last 12 months of life. On average, patients are goals and preferences with family and healthcare providers, and to admitted three times during this period and spend almost 20 days in record and review these preferences if appropriate” [5]. ACP should hospital as a result [2]. While an emergency admission might be nec- provide a comprehensive representation of a patient’s wishes allowing essary, it also reflects wider issues with the provision and planning of treatment to be better tailored in situations where the capacity to par- ticipate in decision making is lost. The complexity of this process, * Corresponding author. potentially involving multiple interactions between patient, healthcare E-mail address: [email protected] (T. Knight). professionals and relatives over time can make communication of an https://doi.org/10.1016/j.eclinm.2019.12.005 2589-5370/© 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/) 2 T. Knight et al. / EClinicalMedicine 19 (2020) 100235 year following admission than patients under sixty [18]. If efforts to Research in context identify patients at an earlier stage of a disease process, and thus offer ACP, were effective, it would be expected that large numbers of Evidence before this study patients would have ACP in place on initial presentation to hospital. Advance care planning (ACP) is a process of discussion about However, little is known about the prevalence of ACP during emer- future care between an individual and their care provider. ACP gency medical admissions. The Society for Acute Medicine Bench- increases the likelihood that care is delivered in accordance with marking Audit (SAMBA) is an annual audit identifying emergency apatient’s prior wishes and communication of the outcome of medical admissions within a single twenty-four hour period which ACP is essential in the acute care setting, where care providers started in 2012 [19] and in 2018 recorded data from 123 acute hospi- are unfamiliar with a patient’s history. ACP is recommended by tals in the UK [20]. This study aims to establish the availability of ACP national bodies but little is known about the availability of ACP on initial presentation to hospital with a medical emergency within decisions in the acute care setting. SAMBA. We also looked see whether factors such as age or readmis- sion within 30 days affected availability of ACP. Added value of this study We report the first nation-wide survey of the availability of ACP 2. Methods to admitting medical teams following acute admission. Very few patients have an ACP that is available during an unsched- SAMBA18 was completed on Thursday 28th June 2018 between uled hospital admission. Even among patients with advanced 00:00 and 23:59. Recruitment to SAMBA18 was open to all hospitals in age, and who have recently been in hospital, the prevalence of the UK receiving acutely unwell medical patients. Non-acute and com- available ACP remains low, in spite of national guidance. munity hospitals were excluded from participating. There are no pub- lished data on the number of AMUs in the UK, therefore, the exact Implications of all the available evidence number of eligible units is unknown. The number of Type 1 Emergency Departments in the UK can be used to provide an approximation given ’ Further interventions are needed to ensure that patients wishes all have provision to admit and manage acutely unwell medical for care are known by providers of acute medical care. Interven- patients. There are 236 type 1 Emergency Departments in the UK [21].
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