End of Life Care in the Acute Hospital Setting Dr Adam Brown Consultant in Palliative Medicine
Learning objectives Understanding a patient's priorities for end of life care How to work with the 5 priorities for care Recognition of the dying patient and prognostication Communication at the end of life Improving end of life care in the acute setting
What is a good death?
A Good Death Being treated as an individual, with dignity and respect Being without pain and other symptoms Being in familiar surroundings Being in the company of close family and friends
Preferred place of care Most people want to die at home if asked but Patients top priorities are: Pain and symptom management Not being a burden Not automatic that home is the best option Need to ensure we are acting in accordance with the patient s priorities Have we asked them?
The reality at present... Not dying in a place they would choose to Poor care in place of death Unnecessary pain and other symptoms Not being treated with dignity and respect
Quality of life?
5 Priorities for Care Guidance developed after the decision to phase out the LCP Patient may die Doesn t require stopping active treatment use of a dual approach Can also offer the opportunity to stop and focus on quality of life or discharge
5 Priorities for Care When it is thought that a person may die in the next few days or hours Recognise: This possibility is recognised and communicated clearly, decisions made and actions taken in accordance with the person s needs and wishes, and these are regularly reviewed and decisions revised accordingly. Communicate: Sensitive communication takes place between staff and the dying person, and those identified as important to them. Involve: The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants. Support: The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. Plan and do: An individual plan of care,, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated ordinated and delivered with compassion.
VOICES survey 2015 National Survey of Bereaved People (VOICES) Quality of care delivered in the last 3 months of life for adults who died in England 7 out of 10 people (69%) rated hospital care as outstanding, excellent or good Care homes (82%) Hospice care (79%) Care at home (79%) 33% reported hospital services did not work well with GP and other services outside the hospital 74% felt hospital was right place for the patient to die Only 3% stated patient wanted to die in hospital
End of Life Care Audit 2016 RCP audit of care in acute hospitals Data collected in 2015 Organisational element and clinical case note review Compared with National care of the dying audit for hospitals 2014 (data 2013) Broad improvements in nearly all aspects of care of the dying in hospitals following phasing out of LCP Concern that gap left after the withdrawal of the LCP would lead to degredation of services Unreasonably wide variation between organisations
End of Life Care Audit 2016 93% of patients whose death was predictable had documentation that they would probably die For half this occurred less than 34 hours before death Only 25% had documented evidence of a discussion with a healthcare professional about this In 95% there was documented discussion with those nominated as important to the dying person A DNACPR order was in place for 94% Discussion about CPR with the patient recorded in 36% 73% had a holistic assessment and plan of care Anticipatory medication for 62-75% of patients CAH in place in the last 24 hours in 43%, CAN in 8%
Improving end of life care Partnership between acute trust and local hospice Joint posts Support for end of life care strategy Focus on improving general end of life care Not increasing numbers seen by SPC team Teaching programme End of Life Care Facilitators Ward based support Multidisciplinary training sessions Support for Link Practitioners Mandatory training through e-learning
Improving end of life care County-wide focus on palliative and end of life care Expert Reference Group Provider Group Education Group Strategic focus on first 2 priorities Recognition Communication County-wide DNACPR form and policy Pharmacy Task and Finish Group Joint hospital and community SPC MDTs.
Recognition 1% of the general population are in the last year of life Scottish hospital study 29% of hospital inpatients in last year 9% in last month Healthcare professionals consistently over-estimate estimate prognosis Especially in non-malignant disease Surprise question Would you be surprised if this patient were to die in the next 6-12 months?
General indicators Prognostication Decreasing activity/increasing dependence Multiple comorbidities Advanced disease Complex/deteriorating symptom burden Decreasing response to treatment Running out of options Repeated admissions No improvement despite hospital admission Weight loss >10% in 6/12 Albumin <25
SPICT tool
Communication Do they want family present? Discuss the patient s priorities with them What do they want from you? They might not want active treatment Where do they want to be cared for? What do they want if (when) they deteriorate? Where would they want to be at the end? Offer to answer any questions they have How long have I got? What will it be like? Can I go home?
Communication Review acute and preventative treatments Plan for nutrition and hydration Discuss CPR Usually explaining why CPR would not be appropriate Medical decision, but they have a right to a second opinion Clear documentation Advance Care Plan Advance Decision to Refuse Treatment Inform GP and community team
Aims for good end of life care Recognition and communication Dual approach where appropriate Recognition of common symptoms Remarkably similar despite diagnosis Effective prescribing Including anticipatory prescribing Review acute and preventative treatments Trial of treatment for 24-48 48 hours then review Plan for nutrition and hydration In accordance with patient s priorities
Dealing with uncertainty Often a lack of evidence in palliative/end of life care No right or wrong answers Need to have a flexible approach Be willing to change course General principles First do no harm Look at patient s priorities Aim for the best possible quality of life for the time they have left Communication is key