73 Using the Gold Standards Framework to Identify Opportunities for Advance Care Planning

Abstract

\n \n \n Departmental discharge data (January 2017–January 2018) suggested a high number of “Day 1 Deaths” i.e. an individual who was readmitted 24\xa0hours after discharge, and subsequently died during their readmission. We wondered if this was due to a lack of Advance Care Planning (ACP).\n \n \n \n We undertook a retrospective case note audit of 50 cases from the “readmissions who died” (total 176/7421) subgroup, to understand whether or not they were predictably within the last days, weeks or months of life and whether there was ACP in place. We reviewed all Day 1 Deaths (16/50), and a random selection of cases across the Day 2–30 (34/50) data set.\n We used the Gold Standards Framework (GSF) as a prognostic tool, by use of the intuitive “surprise question” (“would you be surprised if this person died within the next days, weeks, months?”) and the disease-specific Prognostic Indictors (PI).\n \n \n \n Using the GSF we (retrospectively) predicted death in 94% of the Day 1 deaths and 63% of the Day 2–30 deaths.\n There was evidence of ACP in 32/50 patients (64%), predominantly in the form of a DNAR CPR (61%). There was very little evidence of other forms of ACP.\n Readmissions were justified on the basis of a medical condition in 100% of cases; this was infective in 60% (30/50).\n There were few interactions with secondary care in the 12\xa0months prior to death (mode was 2 admissions in the month prior to death, 4 in the 12\xa0months prior to death).\n \n \n \n We must consider our discharge processes and medical decision making at the front door.\n A Prognostic indicator Tool would be useful to focus medical decision making.\n We must recognise infections as end stage disease in advanced ill health, including advanced frailty.\n We need to consider how we facilitate meaningful involvement of older people in their medical care towards the end of life.\n