bluuebunny/crossref_metadata_2025 huggingface dataset:
X-RAY AUDIT AT PRINCESS ALICE HOSPICE: IS THERE A ROLE FOR ON-SITE X-RAY IMAGING AT HOSPICES?
Authors: Potter Valerie , Gannon Craig
Published: February 2014

Background

A small number of hospices have access to X-ray imaging on-site. A larger number do not and when X-ray imaging is indicated, this necessitates transfer. There is little literature surrounding the use of radiology within the hospice setting. One study in Leeds which looked at requested imaging for inpatient and outpatients over 1 year within a hospice that accessed its local hospital trust for imaging, concluded that most referrals were appropriate. Their study revealed 62 requested scans, 8 being for plain X-rays. This audit was to assess the potential need for in-house X-ray imaging at our hospice.

Aims

Princess Alice Hospice has a 28 bedded inpatient unit. This prospective audit was performed on inpatients over a 6 month period in 2013 to identify cases where an X-ray was considered. It involved recording of all incidences when plain imaging was considered, X-ray type, indication, perceived level of need, appropriateness for transfer and outcome. We audited against the standard that if X-ray imaging is needed, it is performed where necessary and appropriate.

Results

Our audit revealed 18 incidences in total when X-rays were considered over 6 months(11 CXRs, 3 pelvic, 1 shoulder and 3 AXRs). In 4 of the 18 (22%), it was deemed crucial to obtain and all of these patients were transferred. The remaining 14 patients were managed on the basis of clinical findings. 7 of the 18 were appropriate to transfer.

Conclusions

Our results did not provide convincing evidence for access to on-site X-ray imaging. Where it is considered crucial and is appropriate, all patients are being transferred. In our inpatient population, it is often more appropriate to treat clinically. There are both advantages and disadvantages to on-site radiology access and this audit generated limited data. Further work is needed into the availability and appropriateness of imaging in the hospice setting.
WORKING IN PARTNERSHIP: HOSPICE AND HOSPITAL DISCHARGE SUPPORT TEAM INITIATIVE
Authors: Haywood Chris , McConaghy Margaret , Lawton Janet
Published: February 2014

Background

With an ageing population, economic deprivation and poor health, the increasing demand for Specialist Palliative Care (SPC) services is putting pressure on hospice and hospital beds. Audit has shown that where patients with Palliative Care needs express a preference regarding place of dying, over 90% choose their usual place of residence. There is no dedicated workforce available at either hospital or hospice to support transfers and accompany patients and carers to their preferred place of care at the end of life, if necessary staying with them until District Nursing Services and/or carer is in place at the home setting. An innovative approach of a dedicated Hospice Discharge Support Team was established.

Aims

To support routine and rapid discharges (particularly out of hours) from hospital and hospice services to preferred place of care at end of life.

To accompany patient/family on their journey to ensure a smooth transition between services reducing anxiety

To improve Satisfaction of Care by reviewing ‘end of life’ complaints

To reduce hospital deaths where appropriate

Readmission avoidance

Methods

An agreement between Hospice and Acute Services for a 12 month pilot Development of a Hospice Discharge Support Team with appropriate training Initial 85% funding secured through a Grants application to Help the Hospices Quarterly monitoring.

Results

Achievement of patients preferred priorities for care via audit Data used to help to inform Commissioners to secure sustainable funding for continuation of the service Findings included in Quality Accounts.

Conclusion

This service ensures a comprehensive holistic hand-over to the Primary or Care Home Healthcare Team, providing timely support so that necessary equipment and care packages can be put in place to ensure a smooth transition from care settings. This service strengthens stronger working relationships with Acute, Community Services, Care Homes and Specialist Palliative Care Services.
QUALITY END OF LIFE CARE FOR ALL (QELCA) IMPLEMENTATION AND EVALUATION
Authors: Boulton Sophie , Smith Carina , Abel Julian
Published: February 2014

Innovation within the NHS is vital to achieve two aims: firstly and most importantly: improving patient care; secondly saving money, to sustain our healthcare system.

A “good death” was defined in 1997 by the Institute of Medicine as:

“free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' families' wishes; and reasonably consistent with clinical, cultural, and ethical standards”.

In England, some 1,300 people die every day. 60% of these people die in hospital but around 70% would prefer to die at home. Estimates suggest we spend about £55m each day on this failure to give people a good death.

Nationally excellent work is happening to address these issues, and at Weston General we are pioneering in Palliative Care. As F1 doctors we have been working with the Palliative Care team to contribute to the improvements. Weston received a budget to employ specialist palliative care nurses trained by the local hospice to work in each ward of the hospital.

We then put together a computer program allowing data from all deaths to be easily collated. This has allowed us to produce monthly palliative care reports to prove the impact of our new nurses and educate junior doctors on the importance of advanced care planning. We now have a tool that allows us to measure outcomes and monitor adherence to local and national policy regarding end of life care.

With this knowledge comes the power to begin the change, to realise a “good death” for all patients. On our final report we found 51.5% of deaths in our area occurred in people's usual place of residence, the highest in the country. Compiled with other both quantitative and qualitative data we can prove Weston's innovations are striving towards giving people a “good death.”
AN EVALUATION OF A COMMUNITY MULTIDISCIPLINARY TEAM MEETING FOR PATIENTS WITH END STAGE RESPIRATORY DISEASE
Authors: Dando Nicholas , Chiverton Jane
Published: February 2014

Background

NICE quality markers for COPD state that all patients with end stage COPD should have access to specialist palliative care support. To improve identification and management of patients with end stage COPD in North East Hampshire, an integrated multidisciplinary team (MDT) was established between the local hospice, hospital and community teams. This evaluation reviewed the activity of the MDT after 1 year.

Method

The list of patients discussed at each meeting (June 2012 – June 2013) was reviewed and cross referenced with the patient's electronic patient record to determine whether they were referred to the hospice. For patients who were known to the hospice, outcomes including ongoing specialist palliative care input, discharge and place of death were recorded.

Results

34 patients were discussed over 4 meetings. 24 (71%) were already known or referred to the hospice during the year. The majority (74%) had a diagnosis of COPD. 12 (35%) patients died over the year with 58% dying at home or in the hospice. 15 (44%) patients had ongoing specialist palliative care needs requiring input from the hospice MDT as well as the community matron. 2 patients were discharged to the care of the community matron.

Conclusions

A community respiratory MDT meeting provides an important forum for discussion of patients with end stage disease. The meeting facilitates information sharing and coordination of care between the key health professionals involved in the patients management. Although the majority of patients were reviewed by the specialist palliative care team, community matrons remained integral to patient care. As the MDT develops, it will be important to ensure that patients who wish to die at home or in the hospice are identified and supported to meet their wishes. This may result in a reduction in the number of patients dying in the acute hospital environment.
A SPACE TO BREATHE; A HOSPICE BASED, MULTIDISCIPLINARY, PALLIATIVE CARE PROGRAMME FOR PEOPLE WITH SEVERE COPD
Authors: Cambell Fiona , Leek Jo , Hudson Sharon , Colclough Rachael , Pereira Bruce , Sullivan Anita , Davies Charles
Published: February 2014

Background

People with severe COPD have a burden of symptoms, often greater than those with lung cancer and have unmet need (Gore and Brophy 2000). A local palliative care needs analysis was conducted across primary and secondary care. Gaps were identified in the management of anxiety, breathlessness, social isolation, advance planning and carer support. Patients had high comparative admission rate and length of stay.

A team, including a psychologist, OT, palliative and respiratory medicine and physiotherapy and a palliative care CNS, developed and delivered the programme.

The focus of the programme was behavioural change through psycho-education, exercise and relaxation, underpinned by CBT.

Method

Referral was from acute respiratory service for those with at least 2 acute admissions in the previous 6 months, FEV1 of <50% predicted and symptoms of anxiety, fatigue and breathlessness. They attended the hospice programme for 5 weeks with transport provided.

Two programmes were completed with a total of 12 patients and 3 carers

HADS and CATS were taken at week 1 and week 6.

6 month pre and post course admission data was collected.

Results

Patients described; improvement in confidence and quality of life and improved management of their exacerbations. HADS and CATS remained unchanged. Initial data from programme 1 demonstrated reduction in total admissions from 7 to 4 and reduction in total bed days from 47 to 20, over a 6 month period.

Conclusions

Patient evaluated improvement in function and quality of life and reduction in hospital bed days would suggested continuation of the programme with a change in quality of life measurement.
A MIXED METHOD STUDY EXPLORING A PALLIATIVE CARE APPROACH FOR PEOPLE WITH ADVANCED HEART FAILURE
Authors: Gadoud Amy , Macleod Una , Kane Eleanor , Ansell Pat , Johnson Miriam
Published: February 2014

Background

Patients with advanced heart failure have significant unmet palliative care needs. UK policy recommends identification of those requiring palliative care based on prognosis (last year of life).

Aim

To explore aspects of a palliative care approach for people with advanced heart failure: recognition of need, transitions in care and impact on patients, family carers and clinicians.

Methods

Systematic literature review of prognostic variables associated with the last year of life in heart failure. Secondary analysis of contemporaneously collected primary care records from a national database, to compare recognition of the need for palliative care between cancer and heart failure patients. Qualitative semi-structured interviews with patients receiving a palliative approach to care, their carers and clinicians. A mixed method approach with a concurrent triangulation strategy was used; each study was conducted separately and findings were integrated.

Findings

General practice research database (GPRD) data demonstrated gross inequity between documented recognition of the need for a palliative care approach; heart failure patients were poorly represented on the palliative care register and those that were, were registered close to death. Prognostic markers, identified in both the systematic review and GPRD, had limited clinical usefulness for identifying the last year of life. From interview data, clinicians appeared reluctant to discuss a palliative care approach without clear irreversible deterioration of the patient. However, patients welcomed, and some initiated, conversations regarding the change in focus of care. Following such discussion all involved found this approach beneficial, even with subsequent periods of stability or improvement. Other barriers included lack of recognition of symptoms by clinicians and difficulties in delivering proactive care.

Conclusions

A palliative care approach before the very end of life is beneficial in this group. A patient centred, problem-based flexible approach to recognising the need for palliative care, rather than prognosis is recommended.
AUDIT OF PALLIATIVE CARE PATIENT IDENTIFICATION IN GENERAL PRACTICE
Authors: Courtney Richard , Calow Alan
Published: February 2014

Background

The Gold Standards Framework highlights the need for early identification of palliative care patients within the community. Thus allowing optimization of patient care and avoidance of unnecessary treatments near the end of life. The Dying Matters website states GP palliative registers should only have approximately 25% of cancer diagnoses on them.

Aim

To assess if the practice wad correctly registering palliative care patients and what proportion of the palliative register had cancer diagnoses.

Method

Using the GP computer system (Emis) a search was made of the most recent deaths over 7 months. This was cross referenced with the palliative care register at that time to find which patients had not been correctly registered onto the palliative care register prior to their deaths. The notes of these non-palliative care registered deaths were assessed retrospectively to see if the could have been previously added onto the palliative register. Markers within the medical records were previous patient/relative discussion around palliative care, DNAR forms and the use of Prognostic Indicators Guidance.

Results

A total of 33 patient deaths were identified over 7 months. 12 were correctly palliative care registered. 11 deaths could not have been predicted from the records and 10 deaths were expected and therefore eligible for the palliative care register.

Notably 66% of the palliative list had a cancer diagnosis, whereas 9 out of 10 of the unregistered but expected deaths had non-cancer diagnoses. This highlighted clearly that the other common palliative groups were being missed.

Conclusion

Performing such an audit can allow any practice to evaluate their concordance with the current Gold Standards Framework. It re-iterated how the Prognostic Indicator Guidance could be used to identify non-cancer palliative care patients for inclusion onto the palliative register.
SEAMLESS TRANSFER OF CARE FOR END OF LIFE PATIENTS
Authors: Wilde Jane , McDermott Sarah
Published: February 2014

The End Of Life Discharge Facilitators role began in October 2011, designed to facilitate and support timely discharge at End Of Life, for patients who express their wish to be cared for at home through provision of an interface between the acute trust, hospices and District Nursing in Leeds.

The main objectives of the role were to improve collaborative working across organisations and the co-ordination of care provision in the transfer of care to increase the number of deaths in usual place of residence and reduce the number of hospital deaths in line with the vision outlined within the Palliative Care Strategy 2008. Locally it was felt that there were a number of reasons some patients were not always achieving their preferred place of care including:

District Nurse availability to attend a care planning meeting in a timely manner to facilitate the discharge for patients wishing to have end of life care at home.

The role supports the District Nursing teams across the city, not only facilitating seamless transfer of care also contributing to the education and training of ward and community staff around discharge planning.

There are already demonstrable outcomes in terms of facilitating patient choice at end of life. To date the facilitators have supported 350 discharges to preferred place of care.

The iniciative has significantly increased the capacity of the District Nursing teams, as the facilitator completes a quality, robust set of notes, ordering of equipment, ensuring anticipatory medications, DNACPR documentation accompany the patient home where appropriate. This has meant the receiving District Nursing team use their time more effectively with the patient at point of discharge.

The post has further streamlined existing systems and processes re discharge as the facilitators have been able to highlight areas for improvement, enabling them to greatly reduce the numbers of poor/failed discharges.
“IT'S A MARATHON NOT A SPRINT” – SETTING THE PACE IN DEVELOPMENT OF A REGIONAL PALLIATIVE CARE RESEARCH SPECIALTY GROUP
Authors: Lindsay Fiona , Malik Farida
Published: February 2014

Background

Research in palliative care is imperative to improve the evidence base and maintain the best quality care for patients and families. In 2011, the Sussex Cancer Network (SCN) Palliative Care Group identified the need to formally develop a dedicated regional research group.

Aims

To promote palliative care research, with multi-professional representation from specialist palliative care services, throughout Sussex. To increase recruitment to palliative care trials, including development of new research within the region.

Methods

The Sussex Palliative Care Research Specialty Group (SPCRSG) was formed with multi-disciplinary representation from Sussex-wide adult specialist palliative care services and allied research/academic professionals. It is jointly led by the authors and supported by the Surrey & Sussex Comprehensive Local Research Network and formerly by the SCN.

Key activities of the group include: regular education and business meetings, with external expert speakers and Royal College of Physicians CPD approval; regular review of ongoing and potential research studies, particularly those on the NIHR portfolio; promoting research (Good Clinical Practice) training; and linking with established academic centres.

Results

Six hospices, three hospital trusts and two community services have been represented in the five meetings held to date with a median number of attendees of 12 (range 6–17). The usefulness of education sessions have been evaluated as either ‘good’ or ‘excellent’ by 75–88% of attendees. Attendees reported networking opportunities and discussion about independent hospice sector research governance as valuable.

Research activity has increased with involvement in three NIHR Portfolio studies within the Sussex region since the inception of the SPCRSG.

Conclusions

Development of the SPCRSG has been beneficial and would be transferable to other regional palliative care services. To keep up the future pace in providing relevant and effective support and on-going education, it is important to understand what factors promote participation and what barriers to undertaking palliative care research there are.
CLINICAL OUTCOME MEASURES WITHIN A SPECIALIST PALLIATIVE CARE SERVICE (SPCS): DO THEY PROVIDE ADDED VALUE?
Authors: Mayland Catriona , Bayly Joanne
Published: February 2014

Background

Using clinical outcome measures helps support the delivery of high quality care which is amenable to critical evaluation. The project aims were to: identify potential outcome measures; pilot them within clinical settings; and provide recommendations regarding routine clinical use within a SPCS.

Methods

Potential outcome measures were identified and critically evaluated. Three instruments - Palliative care Outcome Scale version 2 (POS-2); Palliative Performance Status (PPS); and Edmonton Functional Assessment Tool (EFAT) – were further assessed in a 2 month pilot within in-patient; out-patient; day therapy and outreach services. Each instrument was assessed on two consecutive occasions (unless the patient died or was discharged).

Results

From 97 patients, 52 (54%) were female and mean age was 68 years (range 27–89 years). POS-2 scores ranged from 1–27 (total score 40=very symptomatic and distressed) with highest scores present for in-patients. Seven patients had POS-2 score >20. All expressed high levels of psychological distress for themselves and their family.

Seventeen (73.9%) of the 25 in-patients had a low PPS score (<50%=considerable assistance needed for self-care). For 9 in-patients with a length of stay >14 days, all bar one had a low PPS score on admission.

EFAT scores showed highest levels of dysfunction were for outreach and in-patients. EFAT's ability to sufficiently discriminate clinically meaningful variations in function within each care setting limited its recommendation for regular use.

Day therapy patients tended to have the lowest POS-2 and EFAT scores.

Conclusions

Following this project, POS-2 and PPS have been incorporated into routine clinical practice within the day therapy unit and more recently in-patient unit. Initial reflections suggest they aid multi-disciplinary team working and highlight particular patient concerns requiring interventions. PPS scores could potentially be linked with length of stay to help anticipate patients with particular complexity and dependency.
WHEN UNPLANNED ACUTE HOSPITAL ATTENDANCE IS APPROPRIATE: DEVELOPING A PATHWAY TO FACILITATE URGENT HOSPITAL REVIEW OF PATIENTS ATTENDING A SPECIALIST PALLIATIVE CARE DAY UNIT
Authors: Turley Maddy , Constable Gemma , Nambisan Vinnie
Published: February 2014

Background

Specialist palliative care services are increasingly accessed by people in the early stages of a life-limiting illness, when functional status may be good and treatment aimed at prolonging life. Whilst avoidance of inappropriate hospital attendance for these patients is desirable, the value ofappropriatehospital attendance should be recognised. We report an audit that appraised and developed the referral process from a specialist palliative care day unit to a local acute hospital for patients with suspected acute medical emergencies.

Method

A retrospective case-note audit was carried out of all emergency referrals made from a specialist palliative care day unit to a local acute NHS trust over a three-month period. Qualitative and quantitative analyses were used to explore: the frequency of, and reasons for, emergency referral; association with primary disease type; the action taken by the acute hospital receiving team; documentation of the event; and clinical outcomes.

Results

We identified nine referrals, equating to 1.3% of day hospice attendances, with all patients having a primary diagnosis of cancer. Reasons for referral (and frequency) included clinical suspicion of: pulmonary embolism; acute cardiac ischaemia; and sepsis. Seven episodes led to hospital admission (length of stay 2–14 days), with all patients subsequently being discharged home.Communication between palliative and acute services was comprehensive at the time of referral, but lacking at the time of discharge.

Discussion

This audit highlights the importance of recognising and taking steps to appropriately manage emergency medical problems in a specialist palliative care patient population. Such problems might occur with increasing frequency as access to specialist palliative care services for those with early-stage disease expands. The results have been used to develop a robust process that uses effective partnership working and communication between palliative and acute services to facilitate appropriate hospital assessment, investigation and treatment.
ARE SUBCUTANEOUS FLUIDS UNDERUSED IN THE HOSPICE SETTING?
Authors: Lowe Emma , Gillon Suzie
Published: February 2014

Background

Subcutaneous (SC) fluids have been shown in several randomised controlled trials to be as effective as intravenous (IV) fluids for the treatment of mild-moderate dehydration, and are probably superior in confused patients. They are associated with reduced equipment costs, nursing time, fewer complications and less patient discomfort. However, they are often underused due to reliance on, and familiarity with the IV route.

Aims

To assess how many patients were receiving fluids within a 32 bed UK hospice and review what proportion could have been appropriate for SC rather than IV fluids.

Methods

140 consecutive hospice inpatient admissions, for which notes were available, were reviewed retrospectively.Data was collected on demographics, indications for fluids as well as type and delivery of fluids. An algorithm to enable selection of SC fluids versus IV fluids within the hospice was drawn up and then used to assess retrospective use.

Results

21 patients (15%) received 26 episodes of fluids during their admission (all via the IV route). All had a malignant disease and had a mean hospice stay of 19 days. 16/21 patients died and 5 were discharged. Fluids were given for an average of 53 hours with 24 episodes delivering 2 litres of fluid or less per 24 hours. Indications were: infection (7), renal impairment/dehydration (6), hypercalcaemia (5), other (8). 24 episodes were assessed as having been suitable for SC fluid delivery although 16 had IV access for another reason. 7 episodes had a documented complication of fluid use, 5 of which related to cannulation.

Conclusions

All the patients in this study were given fluids exclusively via the IV route, but most would have been suitable for SC fluid administration. There is scope for a change in policy to administration more routinely via the SC route.
“PLANNING FOR THE FUTURE”: A TOOL FOR PROMPTING AND RECORDING FOR ADVANCE CARE PLANNING
Authors: Watmough Jonathan , Gunson Eilidh , Sheils Rachel , Ackroyd Rajeena
Published: February 2014

Background

The importance of Advance Care Planning (ACP) is widely recognised. The process can increase patients' chances of achieving their preferred outcomes, prompt them to discuss concerns with their families, and help them to make realistic plans. While some patients want to write advance statements, others do not wish to discuss the future with professionals at all. Another group of patients wants to plan but does not want a patient-held document. Given patients' differing preferences regarding ACP, it would be useful for professionals to keep a record of these specific preferences, as well as broader preferences for future care.

Aims

To develop a document that would (i) prompt professionals to consider ACP consistently, (ii) document the justification when ACP discussions are not offered, and (iii) provide a centralised record of outcomes of ACP discussions. To audit how many of the forms are being completed appropriately once implemented, and the outcomes of using the form.

Method

We designed a proforma (“Planning for the Future”) which is filed at the front of every inpatient's notes, next to any DNA CPR form. In January 2013, we audited proformas for the 55 most recent admissions.

Results

Fifty-one of the 55 patient records contained the "Planning for the Future" form. Fifty one percent (26/51) recorded patients' preferred places of death, 21/51 recorded other wishes and preferences, and 24/51 forms documented formal decision making about whether or not to offer ACP. In 11 of these 24, ACP was deemed inappropriate due to impaired mental capacity or a preference not to discuss the future.

Conclusions

We now have a systematic way of prompting consideration of ACP discussions, indicating whether ACP has been offered, justifying cases where it has not, and centrally documenting a patient's cumulative wishes and preferences. The proforma will be redesigned to increase its use and give our patients the best possible help in planning for the future.
INCREASING ACCESS TO SPECIALIST PALLIATIVE CARE FOR PATIENTS WITH NON-MALIGNANT DISEASE: A ‘BIG BANG’ APPROACH
Authors: Hayle Catherine , Ahmad Fawad , Emms Helen , Lewis-Jones Catherine
Published: February 2014

Background

Access to specialist palliative care for patients with advanced non-cancer diagnoses is much lower than for those with cancer, despite a similar symptom burden and poor health-related quality of life. Wirral Hospice St John's sought to address this inequality through the appointment of a consultant in palliative medicine with a specific remit to increase access for patients with non-malignant disease.

Aim

To monitor the proportion of hospice referrals for patients with non-malignant disease over a three-month period at the start of the initiative.

Methods

Cross-sector work was undertaken to publicise the project. A letter was sent to all GPs, and a variety of educational events for GPs, community matrons and specialist nurses were held. Secondary care was approached via individual specialty meetings, consultant physicians' meetings and a postgraduate education event. Close liaison with the Clinical Commissioning Group was ongoing throughout. Education and listening events for hospice staff (clinical and non-clinical) were conducted, and updates regarding specific conditions organised. Data regarding referral patterns were collected contemporaneously.

Results

Referrals to all services for patients with a primary non-cancer diagnosis increased steadily from 5.7% (May'13) to 18.2% (Aug'13). The increase was most pronounced in day therapy (6.9% to 30.8%), followed by inpatient care (2.5% to 13.5%), and outpatient services (8.3% to 16.7%). The majority of referrals were for patients with respiratory disease (69%), followed by neurological disease (22%).

Conclusions

It is possible to increase access to specialist palliative care for patients with non-cancer disease within a short timescale. Dedicated time to liaise with colleagues in primary and secondary care is vital to achieve this. Robust monitoring of referral patterns and service capacity, together with education for hospice staff is also important in order to maintain a safe, high quality service. Work is ongoing to ensure equity of access between disease groups.
A COMMUNITY PALLIATIVE CARE NURSE SPECIALIST LED INTERVENTION TO IMPROVE PALLIATIVE CARE IN CARE HOMES: PRELIMINARY RESULTS
Authors: Finucane Anne M , Gardner Hilary , Stevenson Barbara , Muir Lynn , Gibson Hilary , Barker Liz , Murray Scott A.
Published: February 2014

Background

Approximately 20% of people die in long term care settings. National and international policies call for care homes to provide reliably good end-of-life care. Specialist palliative care providers are well placed to support care homes to deliver palliative care to residents who would benefit.

Aim

To improve the delivery of palliative care in care home using a community palliative care clinical nurse specialist (CNS) model of support.

Results

Twenty-two South Edinburgh nursing care homes agreed to take part in this project. Eight took part in Phase 1. After death audit data was collected in each care home following the death of a resident at baseline (i.e. prior to the intervention), and once the intervention had started.

Components of the intervention were: support from a dedicated Community Palliative Care Clinical Nurse Specialist; identification of two palliative care leads in each care home; palliative care training; multidisciplinary palliative care review meetings, and support to use tools to help identify residents approaching end of life.

Baseline data relating to 77 residents was collected: 92% of residents died in the care home; 64% had a record of anticipatory care planning; 19% died on an integrated care pathway and 55% had anticipatory medicines prescribed. The intervention is continuing. Data on outcomes during the intervention period will be compared against the baseline data.

Conclusion

Our study explores the extent to which a community palliative care nurse specialist led model of care home support enables care home staff to improve the delivery of palliative care to their residents. The findings will inform the delivery of the intervention to 14 care homes in Phase 2. More generally, this project will guide the design of new palliative care interventions that will allow palliative care specialists to extend their influence to reach patients with frailty and dementia.
IDENTIFICATION OF THE MOST COMMONLY PRESCRIBED OPIOID FOR ADMINISTRATION BY CONTINUOUS SUBCUTANEOUS INFUSION
Authors: Dickman Andrew
Published: February 2014

Background

Continuous subcutaneous infusions (CSCI) are commonly used to maintain symptom control once the oral route is no longer available. In 2004, there was a worldwide shortage of diamorphine and most centres adopted morphine as the opioid of choice. Diamorphine has since become available again, but it is more expensive than morphine. A national survey of UK practice performed in summer 2004 identified diamorphine as the most commonly prescribed opioid for administration by CSCI. No survey of national practice has been performed since.

Aims

To identify the most commonly prescribed opioid for administration by CSCI in the UK and to compare with local practice.

Method

UK pharmacists and pharmacy technicians were invited to complete an internet-based national survey of current practice. For each CSCI, participants recorded information about constituent drugs, doses, diluent, total volume, duration of administration and visual appearance. A sub-analysis of the data was performed in order to identify the frequency of opioid prescribing. The results were compared to those obtained from local practice.

Results

A total of 2000 CSCIs were recorded in the national survey by 35 centres distributed across the UK. Morphine was the most commonly prescribed opioid, occurring in 28% of CSCIs. Oxycodone was the second most frequently prescribed opioid, followed by alfentanil and diamorphine. Analysis of local practice identified morphine as the most commonly prescribed opioid, with alfentanil being the second, followed by oxycodone and diamorphine.

Conclusion

Morphine has been shown to be the most commonly prescribed opioid for administration by CSCI.
AN AUDIT OF DOCUMENTED REFERRAL INFORMATION FOR CHILDREN REFERRED TO A UK PAEDIATRIC AND YOUNG PERSON'S HOSPICE
Authors: McKeating Catriona , Koodiyedath Bindu , Nicholson Johanna , Miller Mike
Published: February 2014

Background

Recent research shows a rising national prevalence of Life Limiting Conditions in children identifying an escalating need for paediatric palliative care services in the UK.1Hospice services must ensure quality, sustainable care and essential to providing this is the careful documentation and consideration of all referred patients.

The services offered by paediatric hospice settings vary widely throughout the UK. Such individual care settings require individualised referral processes and individualised referral documentation.

Martin House Children's Hospice in Yorkshire looks after 340 children and young people with life limiting illnesses from birth to age 35 years. The hospice receives approximately 87 new referrals on average (mean) per calendar year for children aged 0–19 years.

Aims

To undertake an audit assessing the quality of information recorded on hospice referral forms against the Scottish Intercollegiate Guidelines Network 31 template.2SIGN 31 is a valid “gold standard” for audit of current practice and recommended as a suitable tool to ensure quality in referral communication. Half of all referrals received during a 6 month period at Martin House were retrospectively examined for the recommended minimum essential information within SIGN 31.

Results

The audit Identified incomplete and inconsistent documentation in recording of referrer contact information, reason for referral and child/young person's location at the time of referral.

The audit highlighted other inconsistently documented information out-with the recommendations of SIGN 31 guidance considered important for paediatric palliative care referrals. This included the order of referral (i.e. first/second), parental and child's consent to and awareness of the referral, languages and religious beliefs of the child and family, parent's names and legal guardianship status.

Conclusions

The audited referral documentation and referral system is not presently in-line with the ‘gold standard’ SIGN 31 guidance and requires improved consistency in documentation of the required minimum data set to ensure quality care for children referred to the hospice service.
DIFFERENT DYINGS: LIVING AND DYING WITH CANCER, ORGAN FAILURE AND PHYSICAL FRAILTY
Authors: Kendall Marilyn , Carduff Emma , Lloyd Anna , Kimbell Barbara , Cavers Debbie , Buckingham Susan , Boyd Kirsty , Grant Liz , Worth Allison , Pinnock Hillary , Sheikh Aziz , Murray Scott A.
Published: February 2014

Background

Recent controversy around the Liverpool Care Pathway has highlighted the need to listen to patient and carer perspectives. Better understanding of how different patient groups perceive their deteriorating health and approaching death can inform palliative care developments for all conditions.

Aim

To establish whether there are typical narratives of living with and dying from a variety of progressive conditions, that might provide insights into how best to provide effective, patient-centred care.

Methods

We used a narrative framework to synthesise eight methodologically comparable, longitudinal, interview studies undertaken by our research group. We examined the narratives of people dying from cancer (lung, glioma and colorectal cancer), organ failure (heart, liver and chronic obstructive pulmonary disease) and physical frailty, in socioeconomically and racially diverse populations in Scotland.

Results

The dataset comprised 828 in-depth interviews with 156 patients, 114 family caregivers and 170 health professionals. The cancer narratives typically had a clear beginning, middle and anticipated end. They gave a well-rehearsed account of the illness, with the dual themes of hope for recovery alongside fear of dying. In contrast, people with organ failure struggled to pinpoint when their illness began, or see meaningful patterns between acute events. Fewer spoke about death, hoping instead to avoid further deterioration. Some attributed their poor health to ‘old age’, others struggled to identify any specific illness. Frail older people were frustrated by their progressive loss of independence, fearing dementia or nursing home admission more than dying.

Conclusions

The typical cancer narrative is very different from those in frailty or organ failure. Palliative care as a concept may be too inextricably linked to imminent death to be acceptable and appropriate for these patients. We must diversify palliative care provision to meet the range of holistic needs of all patients approaching the end of life.
BEFORE THE TIPPING POINT: USING A COMPUTER RECORD SEARCH TO AID IDENTIFICATION OF PATIENTS WITH PALLIATIVE CARE NEEDS IN PRIMARY CARE
Authors: Mason Bruce , Boyd Kirsty , Campbell Christine , Steyn John , Kendall Marilyn , Murchie Peter , Murray Scott
Published: February 2014

Background

Primary care is involved in the delivery of end-of-life care for approximately 600,000 people per year in the UK. Many patients who might benefit from proactive interventions at this time are not receiving them because they are not being identified as having “palliative” needs. The use of information technology currently in place in general practices provides opportunities to enhance identification of patients with such needs.

Aims

To develop and test a primary care electronic record search to identify patients with palliative care needs who are not already on a palliative care register. To assess the feasibility of such a search and its acceptability to primary care professionals.

Methods

A computer record search was developed then tested in a sample of practices in two Scottish health boards. Quantitative and qualitative data was collected to test the appropriateness of the search results and professional attitudes towards the method.

Results

The search was run in 10 practices with a total patient population of 83,229 and 69 health professionals present. For each practice, the search generated matches equal to 0.75% to 1.6% of the practice patient population. 30–60% of the patients returned by each search were considered to be at risk of dying by at least one GP. GPs struggled to suggest what additional care they could offer and found the term “palliative care” unhelpful. Although GPs found the search to be a useful tool they expressed reluctance to increase the size of their palliative care register.

Conclusions

The search successfully made GPs aware of patients who have palliative care needs. However GP attitudes towards palliative care meant that they lacked appropriate actions to take. This computer search is potentially useful but only if it can be paired with actions that can be taken without requiring use of the term “palliative care.”
AN INTEGRATED MODEL OF SPECIALIST PALLIATIVE CARE (SPC) FOR CYSTIC FIBROSIS (CF)
Authors: Quibell Rachel , Booth Zoe , Doe Simon , Bourke Stephen J
Published: February 2014

Background

Specialist palliative care (SPC) for patients with Cystic Fibrosis (CF) is complex as they have severe symptoms requiring active CF treatment and some die on a transplant waiting list, which may be a barrier to referral for SPC. We describe a model of care whereby the SPC team is part of the CF team providing SPC alongside CF care.

Results

Of 270 CF patients, 20 (9 male; mean age 32.3 (19–47) years) had SPC input over 2 years. They had advanced CF (mean FEV125%; BMI 19.7); 9 patients died, 3 underwent successful transplantation and 9 are in ongoing care (2 on active transplant list). Prominent symptoms on assessment were dyspnoea (85%), cough (80%), pain (75%), nausea or vomiting (75%), fatigue (55%) anxiety (50%) and low mood (30%). SPC interventions included drug advice, non-drug measures for management of symptoms (relaxation, massage, acupuncture), practical provision of equipment, activity based therapy, financial advice, and psychosocial and spiritual support. Deaths were in hospital after a short final exacerbation. SPC have been involved in the end of life care of all that died. Evaluation showed that all of the CF team felt that SPC should be a part of the team, and rated SPC highly (mean score 4.1 on a 5 point scale). The CF Team perceived that all patients had found SPC helpful or very helpful. Only one patient awaiting transplant declined SPC input.

Conclusions

This model is successful in overcoming barriers to SPC and is highly rated by the CF team. The SPC team have developed their knowledge of CF, and find it helpful to meet patients and families earlier. This integrated model of SPC is applicable to other specialist diseases.
USING THE “PATIENT DIGNITY QUESTION” AS A PERSON-CENTRED INTERVENTION FOR PATIENTS WITH PALLIATIVE CARE NEEDS IN AN ACUTE HOSPITAL SETTING
Authors: Gaffney Marion , Johnston Bridget , Buchanan Deans
Published: February 2014

Background

The aim of palliative care is to improve the quality of life of patients who are living with a progressive, life threatening illness. In order to achieve this, the patient needs to be cared for as a person. However, current research indicates that this is not always achieved in the acute hospital setting.

Aim

This feasibility study set out to determine the practicalities and effectiveness of using the ‘Patient Dignity Question’, (Chochinov 2010) an intervention derived from extensive, empirical research on dignity near the end of life, in order to enhance person-centred care.

Methods

A mixed methods feasibility study using both patient reported outcomes measures (person centred climate questionnaire PCCQ; Patient Dignity Question questionnaire (developed by Chochinov et al), and semi-structured interviews was adopted underpinned by pragmatic theory. The study was conducted in a large teaching hospital with a purposive sample of nine patients and five healthcare professionals.

Results

The results of indicate that is feasible to carry out this type of study for people with palliative needs in the acute care setting. Adopting a mixed methods approach was effective in answering the research questions and meeting the study aims. The primary outcome measure was effective in determining the person-centred nature of the hospital climate. However, it was unable to determine if the ‘Patient Dignity Question’ had a direct influence on this.

Conclusion

Study participants were willing and happy to take part in this study despite their illness and environment. Participants found the ‘Patient Dignity Question’ and summary both useful and practical. They described it as an intervention that can help to improve the care patients receive and help them feel valued as an individual. A funded study with 30 patient, 30 family members and 30 health professionals is now being undertaken with a before and after trial design.
ATTITUDES AND EXPERIENCE OF TRAINEES IN PALLIATIVE MEDICINE TO ABDOMINAL PARACENTESIS
Authors: Hitchens Morwenna , Bush Harriet
Published: February 2014

Background

Abdominal paracentesis is widely used as a symptom control measure for malignant ascites. In the UK, ultrasound guided insertion has become standard practice in some specialist palliative care units. This has resulted in variation in practice between units, inconsistent training opportunities and perceived difficulties for trainees to achieve procedural competencies.

Aim

The aim of this study was to establish the views of Palliative Medicine trainees on their experience, competency and the role of ultrasound in paracentesis.

Methods

An online questionnaire was sent out to all trainees registered with The Association of Palliative Medicine. 81/230 trainees responded (35%). 72 % were in their final year of training.

Results

In the preceding 12 months 75% of trainees had performed paracentesis on less than three occasions, 39% had not put in a single drain. 49% of trainees anticipated difficulties in achieving the required procedural competence by the end of training due to fewer opportunities, often having to arrange specific clinical attachments to meet the training objectives. In 33% of units all cases were ultrasound guided yet only 5/81 trainees were trained to use ultrasound. 78% trainees felt competent to insert a drain without ultrasound although 39% believed all drains should be placed under ultrasound guidance.

Conclusions

Paracentesis is a mandatory skill required to complete training in Palliative Medicine. This study has shown that many units only perform ultrasound guided procedures and yet only 6% of trainees are trained in this technique. Therefore there are fewer opportunities for training as evidenced by 39% of trainees not performing paracentesis within 12 months. Most still feel competent to perform paracentesis but this study raises questions regarding maintaining procedural competency and who will train the trainees in the future. If the trend towards ultrasound guidance continues it should become a skill all trainees must learn.