Completion of an advance care plan (ACP) with patients with advanced neurological conditions, the evidence

BackgroundAs a result of service development through COVID-19, a community based Speciality Doctor was recruited to write ACPs for patients with progressive advanced neurological conditions through domiciliary visits. This study seeks to understand how their ACP may benefit patients and their primary health care providers (PHCP).MethodsRetrospective cohort study, examining electronic hospital records 3 months pre-ACP/3 months post-ACP of 36 patientsOnline survey of patient’s named PHCPResults36 patients were reviewed, diagnoses included advanced Parkinson’s disease/Parkinson’s plus, secondary multiple sclerosis, NF1 and superficial siderosis. 2 of these patients were known to hospice services before ACP commencement.5 patients died since their ACP was made, all in their preferred place of care (home), with anticipatory medications, and without hospital or hospice input at end of life. Comparing 3 months pre to 3 months post ACP, ED attendances reduced from 35 to 9, and acute hospital inpatient stays reduced from 16 to 5 (136 to 21 bed days). 9 of 26 PHCPs surveyed replied. 89% (8) knew about the ACP but none had used it so far to make a clinical decision. 89% (8) felt confident of what an ACP is (8+/10 self scoring) with 33% (3) very confident to complete/review themselves. All responders felt happy for an ACP to be completed on behalf of them, concluding that it should be done by the ‘most appropriate’ ‘experienced clinician’ who ‘knows the patient best’.ConclusionsThis study demonstrates the benefit from ACP in terms of achieving PPOC and avoiding hospital admissions. For these 36 patients, there were potentially 11 acute hospital admissions avoided, with a reduction in 115 bed days.Data will be extended by a further 3 months by the time of the PCC. Future work gauging patient’s and carer’s opinion of ACP is planned.

Allocation of Scarce Resources in a Pandemic: A Systematic Review of US State Crisis Standards of Care Documents.

The aim of this systematic review was to locate and analyze United States state crisis standards of care (CSC) documents to determine their prevalence and quality. Following PRISMA guidelines, Google search for "allocation of scarce resources" and "crisis standards of care (CSC)" for each state. We analyzed the plans based on the 2009 Institute of Medicine (IOM) report, which provided guidance for establishing CSC for use in disaster situations, as well as the 2014 CHEST consensus statement's 11 core topic areas. The search yielded 42 state documents, and we excluded 11 that were not CSC plans. Of the 31 included plans, 13 plans were written for an "all hazards" approach, while 18 were pandemic influenza specific. Eighteen had strong ethical grounding. Twenty-one plans had integrated and ongoing community and provider engagement, education, and communication. Twenty-two had assurances regarding legal authority and environment. Sixteen plans had clear indicators, triggers, and lines of responsibility. Finally, 28 had evidence-based clinical processes and operations. Five plans contained all 5 IOM elements: Arizona, Colorado, Minnesota, Nevada, and Vermont. Colorado and Minnesota have all hazards documents and processes for both adult and pediatric populations and could be considered exemplars for other states.