Advance Care Planning: A case study by Dr Joe Cosgrove

5 Apr

Introduction

Advance Care Planning stories can bring to life the impact of planning ahead. I am proud to be hosting guest blogs, and this week to feature Advance Care Planning in the form of a case study and discussion with Dr Joe Cosgrove, a Consultant in Anaesthesia.

Dr Cosgrove describes an example of Advance Care Planning in practice, explaining the background to an anonymised patient case, what happened and lessons to be learned. It is a masterclass in proactive, personalised planning demonstrating zooming out, or seeing the long-term illness in an acute healthcare situation.

The blog closes with key messages for Advance Care Planning in a chronic and severe illness.

Thank you, Dr Cosgrove.

Clare: Hi, thank you for creating this blog, can we start by you telling me a little about you and your role?

Joe:Thanks Clare. I grew up in the Late 1960s and 70s in the North-East of England. I attended Newcastle University in 1983 and graduated with a Medical Degree in 1988. Since then, I’ve worked (largely) in Acute Specialties and have been a Consultant in Anaesthesia in Newcastle upon Tyne since 2001. Until September 2022 this included a majority commitment to Adult Intensive Care Medicine.

Clare: Was there a specific catalyst for your interest in Advance Care Planning or how did your interest in Advance Care Planning develop?

Joe: I have an adolescent memory where an adult relative refused some cancer treatments that were offered to them because they felt the treatments offered little to their quality of life, so I guess this is arguably a catalyst. However, I would suggest that professionally my work in acute specialties, especially Perioperative and Critical Care has driven a longer-term involvement in Advance Care Planning (ACP.) Seeing poor physiological and psychological outcomes in survivors of Intensive Care and/or Major Surgery has motivated me to attempt to explain to patients, the public and colleagues, not only the benefits of serious medical treatments but also the burdens that can occur when such treatments fail to achieve the desired outcomes.

As a Consultant I’ve also had the privilege of having Dr Kath Mannix as a colleague and have worked constructively with her and her Palliative Care colleagues to promote Advance Care Planning and good End-of-Life Care (EoLC.) This has resulted in me leading a project (2017-19) related to EoLC and ACP on behalf of the Faculty of Intensive Care Medicine (FICM) and playing a major role in my NHS Trust in promoting ACP before and during the COVID-19 Pandemic. I have also (previously) represented FICM and the Royal College of Anaesthetists (RCoA) at the National Audit for Care at the End of Life (NACEL.)

Can you give an example of Advance Care Planning in your practice?

Joe: The most recent example relates to a patient I was scheduled to anaesthetise a few months ago. I’d read their notes the evening before and it was clear that the patient was “high-risk” for even elective surgery, owing to their co-morbidities.

Patient history

Recently I performed a preoperative visit in order to review a male patient in their late 60s on a Vascular Surgical operating list who had been scheduled for an expedited (rather than emergency) above knee amputation. His background history was as follows:

Peripheral vascular disease and wheelchair bound due to resting leg pain
Severe COPD having been a smoker since his teenage years. He was continuing to smoke 30/day and had recently finished a course of antibiotics and steroids from GP for an infective exacerbation of his COPD
BMI 17, with a very poor diet
He admitted to drinking 8 cans of lager a day and 4-6 whiskies

Background

He lived alone but was visited regularly by his ex-partner and one of his step-children would perform a weekly shop. His house was in an area of high social deprivation and apart from his recent GP review re the exacerbation of COPD, he admitted that he rarely visited his doctor.

What happened

The surgical trainee who’d seen the patient in order to take consent for surgery expressed concerns to me about the patient’s fitness and in addition to their chronic health problems felt that they were acutely unwell.

On review of the patient, it was clear that we would have to postpone surgery due to his poor respiratory function. This gave me the opportunity to explore matters further with the patient, his ex-partner and the surgical team. He had full capacity and on discussion realised that he was probably in the last year of his life. He volunteered that he’d seen a step-son die on an ICU (whilst receiving ECMO or Extra-Corporeal Membrane Oxygenation) from severe acute pancreatitis. He’d also seen his father-in-law die from pneumonia and sepsis, also on an ICU. During this discussion he also became very adamant that he felt CPR would be a burden to him but hadn’t discussed such matters with anyone. In summary we had a very constructive discussion (lasting almost an hour) about what would be appropriate care and treatment for his individual needs. This culminated in the following Advance Care Plan/Treatment Escalation Plan:

Referral to Respiratory Medicine to see if there was any potential for physiological optimisation prior to the proposed surgery. He was subsequently admitted as an in-patient
An agreement that if, despite optimisation surgery became impractical/impossible consultations with Palliative Care would be better approach. Clarifying and reassuring that such a referral did not mean that “he was going to die in the next few days” or “that we were writing him off.”
DNACPR and an agreement for a possible trial of CPAP/NIV in the event of another severe acute exacerbation of his COPD, noting that he could still veto this

In summary, it’s my view that the whole process worked well and everything and everyone was left with a degree of clarity. Nevertheless, there are so many things to take away and further explore as on another day there would have been no ACP put in place and the patient may not have felt empowered to voice their views on potential burdensome treatments which could have meant that they “slipped through a net.”

Clare: It sounds as if that truly person-centred Advance Care Planning, taking into account the patient’s wishes, past experiences and current health status. What is the key message or messages you would like to share with Health Care Professionals?

Joe: Patients with severe chronic illness have a high chance of being in their last few years of life and the best time to have discussions about Advance Care Planning is when they are relatively stable and not suffering from an acute illness. Such times also afford an increased ability to have multiple discussions, rather than a fraught discussion when the patient is so unwell that they are unable to contribute in a meaningful way.

Using information about chronic disease from the Gold Standards Framework or the Scottish SPICTTM Criteria (Supportive Palliative Care Indicators Tool) can be useful in guiding patient selection and shared decisions.

And what is the key message or messages you would like to share with the public?

Joe: If you feel you wish to discuss the potential burdens of treatment (as well as presumed advantages) with a health care practitioner because you feel such treatments wouldn’t offer you any improvement in the quality of your life, please feel empowered to do so. And even if the healthcare professional is unable to offer your immediate or precise advice, they should be able to advise you about who could offer such advice. Most importantly, however please also have these discussion with your loved ones.

Clare Fuller