Anticipatory care planning

Anticipatory Care Planning in primary care: an after-death analysis of electronic Key Information Summaries.

GPs are caring for increasing numbers of elderly patients approaching end of life with various and often multiple illnesses.

Anticipatory Care Planning (ACP) is central to chronic disease management and palliative care, allowing patients, and their family carers, a chance to think about their future, consider what they do or do not want to happen and who may speak on their behalf.

ACP needs to be easily started, updated and accessible and electronic Key Information Summaries (KIS) were introduced throughout Scotland in 2013 for this purpose. These electronic records, completed, updated and shared by GPs, are accessible to health care providers including NHS 24, Ambulance services, out of hours GPs, Accident and Emergency and hospitals.

We are undertaking a retrospective study of ten GP practices looking at all patients who died in 2014. Quantitative analysis of deceased’s records for KIS completion and the quality of records completed along with review of records to identify which disease trajectory patients died on and their preferred place of care.

We will describe how KIS are being used in ACP, discuss how the different disease trajectories impact on ACP, and explore the strong association of ACP with dying outside hospital. We will provide insight into GPs experiences of ACP, identify areas of good practice and make recommendations for improvement.

Funder

University of Edinburgh and NHS Lothian

Research team

Julia Tapsfield, Carey Lunan, Peter McLoughlin, Hazel McCutheon, Juliet Spiller, Scott Murray