bluuebunny/crossref_metadata_2025 huggingface dataset:
Sedation: understanding a normative basis for its use
Authors: Frew Katie , Hughes Julian , Paes Paul , Exley Catherine
Published: March 2012

Background

Sedation is a controversial issue in palliative care. Previous research has explored aspects of administration, concerns of relatives and staff and also ethical issues, predominately in retrospective studies. These studies suggest that the authors require prospective observational research into the day to day use of sedation.

Aims

The aim of this research was to describe the normative underpinnings of current hospice practice with respect to the use of sedation in palliative care.

Methods

This is an ethnographic study of the use of sedation in a palliative care inpatient unit. The primary research methods were participant observation and indepth interviewing. Data was analysed taking a constructivist grounded theory approach.

Results

Through data analysis three overarching concepts were developed. These were i) the concept of ‘routine’ sedation; ii) the relationship of sedation to ensuring a good dying and death; iii) the fundamental role of values in the use of sedation. This paper will consider the second of these. The use of sedation at the end of life was found to be motivated by healthcare professionals' desire to bring about good dying and death. This ‘good dying’ centred on symptom control and relief of distress with the aim of bringing about what was conceptualised as a ‘natural’ death, that is dying in sleep. Sedation was used to facilitate this process.

Conclusion

This research provides the first empirical evidence of the normative basis to the use of sedation, which lies in the hospice construct of good dying and death. This has important implications for the specialty as it expands to provide care for patients with different illnesses and dying trajectories. Uncertainty about diagnosing dying raises challenges regarding the use of sedation, especially when continuous sedation is used until death. The desire to bring about good dying must be balanced by good decision-making in uncertainty.
A qualitative study exploring patients experience of ACS and a structured approach to its management
Authors: Waterfield Kerry , Andrew Inga , Macnaughton Jane , Hawkins Colette
Published: March 2012

Background

Anorexia Cachexia syndrome (ACS) is a common and devastating condition in cancer patients. It is poorly defined and heterogeneous, with many difficulties in conducting research and translating those findings into practice. A literature review revealed that patients' experience of the care offered by healthcare professionals was generally negative. Professionals were seen to avoid the issue or offer scanty/ineffective advice. It was hypothesised that proactive, systematic management could overcome some of these barriers. This was seen in an interventional study of such an approach, QISAM (Quantifying the impact of Standardised Assessment and Management).

Aims

The aim of this qualitative study was to increase understanding of the experience of ACS from the individual patient perspective and to determine how taking part in QISAM impacted upon this experience. It also aimed to determine why the intervention had been beneficial and help with the process of translating the results of that study into practice.

Method

Ten patients suffering from ACS who had participated in QISAM were interviewed postintervention in their homes using a semistructured approach. Interviews were transcribed verbatim and analysed using an interpretative phenomenological approach.

Results

A common experience of patients was a struggle with the lack of control or uncertainty they faced. The huge anxiety linked to ACS was also apparent. Participating in QISAM seemed to help patients regain a little of that sense of control as they learned to manage their symptoms and access help. The structured approach of QISAM, including the practical advice given, provided much needed reassurance.

Conclusions

This study is the first to explore patient's experience of an intervention to address ACS. The results support previous findings of the significant impact of the condition. It suggests the benefit of the intervention was influenced by the fact that patients felt reassured and empowered.
Exercise rehabilitation for cancer related fatigue: home or gym based?
Authors: Watson Max , Dunwoody Lynn , Payne Cathy
Published: March 2012

Background

As people live longer the number living with and beyond cancer is increasing. Due to the after effects of disease and treatments many individuals who survive cancer do not enjoy the same quality of life as the general population. The aftercare for this population is largely biomedical in orientation, focusing on monitoring and surveillance of recurrence. However, research highlights the importance of well-being and the use of exercise rehabilitation in the management of CRF.

Objectives

The Back on Track (BoT) 8 week pilot service for patients with CRF, evaluated the feasibility of providing an individually tailored exercise rehabilitation programme based on evidence gathered from multiple trials into the use of rehabilitation interventions for CRF.

Method

Individuals who had completed cancer treatment were recruited from the membership of the Ulster Cancer Foundation. A holistic baseline assessment of the 18 participants was carried out at the Health and Rehabilitation Sciences Research Institute (HRSRI), University of Ulster. A personalised 8 week exercise programme was agreed with each participant. 12 participants chose to partake of a home-based aerobic and resistance training programme with weekly telephone support and six chose an additional weekly exercise programme at the HRSRI. On completion the initial assesments were repeated. 17 of 18 participants completed the baseline and follow up assessments.

Results

Significant improvements were noted in the 6 min Walk Test (6MWT), the Fatigue VAS, the FACT-F, the Beck Depression Inventory, the BORG scale post 6MWT, Triceps skin-fold thickness and timed sit to stand. These improvements were achieved in both the home based and gym supported groups. A change in lean body mass was noted.

Conclusion

An 8 week home-based exercise rehabilitation programme with or without weekly gym based activity makes significant improvements to both physical and psychosocial outcomes in patients with CRF.
End of life template, summary care record, Vertical Integration – sorted!
Authors: Plenderleith Stephen , Clack Sam , Nightingale Tracy
Published: March 2012

Following presentation, at the HtH Bournemouth Conference 2011, of the project scope and technical solutions used to deliver the Summary Care Record End of Life Template, this poster looks at the project evaluation. Results of the staff and patient/carer evaluation will be presented along with lessons learnt and suggestions for future developments. This project, supported by a grant from West Midlands Workforce Deanery, is working across South Birmingham EoL care services to pilot an end of life ‘significant conversations’ template. The information from this is then made available via the Summary Care Record to acute services; West Midlands ambulance, Primecare OH services, PCT drop in centres and the Accident and Emergency department. Patients do not want to have to give the same information over and over again and yet the Gold Standards Framework, Holistic Needs Assessment, Preferred Priorities of Care and Liverpool Care Pathway documents all cover similar ground again and again. No pilot of any nationally recommended ‘pathway’ document, has so far seriously addressed the need for information to travel with the patient. Patient held records, though trialled in some areas, have the ever present problem of being forgotten or lost and so often lead to clinical staff having to duplicate their clinical entries. The template is being trialled in seven GP practices on four different GP systems (potentially covering over 95% of patients nationally). ‘Significant conversations’ data will be collected in primary care, hospital and hospice settings. Daily automatic transfer of data back to the patients' primary care record will ensure the GP is kept up to date and that the SCR record remains current for use by any service providing on-going or acute care to patients.
NHS south of tyne and wear's (SOTW) supportive and palliative care standards for end of life care in primary care
Authors: Watson Louise , Richardson Jackie
Published: March 2012

The end of life strategy (2008) has set key recommendations as to what constitutes high quality care at end of life. In light of this ground-breaking document, and following on from the Keep Improving the Experience (KITE, 2006–2009 used as an alternative to Gold Standards Framework) project across SoTW, a new set of eight standards for supportive and palliative care were developed locally. An initial qualitative baseline pilot was carried out across SOTW examining the workability of these standards, followed by a project with a single practice based commissioning group to further test their feasibility and to demonstrate the value of the standards in primary care. Initial phase workshops were followed by in-depth, practice-based sessions which afforded individualised and focused support for participating practices. Key areas of improvement were:

Identifying patients in the last 6 to 12 months of life

Managing palliative care registers

Managing multidisciplinary team meetings

Proactively planning palliative care

Communication and co-ordination of care.

Practices worked to uplift from their baseline assessment by demonstrating progression with supporting evidence to achieve accredited status. The results have been encouraging although it is not possible to fully evaluate the impact of the Standards in terms of clinical outcomes as this data is not yet available (eg, quality outcomes framework). However, qualitative feedback from practices who achieved accreditation is overwhelmingly positive. In particular the one-to-one support was highly valued and the standards themselves have attracted positive feedback, in both this project and the pilot. The authors believe that it is this combined approach which is of most benefit in primary care. The evidence suggests that it is a workable model for other clinical commissioning groups to adopt. Furthermore, practices previously KITE-accredited have consistently demonstrated continued improvement over several years, indicating that the model is also sustainable.
NHS south of Tyne and Wear's supportive and palliative care standards for end of life care in care homes
Authors: Watson Louise , Richardson Jackie
Published: March 2012

Around 500 000 people die in England each year. The vast majority (around 99%) of deaths occur in adults over the age of 18 years. Most deaths occur in people over 65 years and this group is expected to increase in numbers over the next decade as our population ages. The Improving supportive & palliative care for adults with cancer (National Institute for Clinical Excellence 2004) defined service models required to ensure that people with cancer, their families and other carers receive support to help them cope with cancer and its treatment. In response to this, NHS South of Tyne and Wear (Organisation's name predating Transforming Community Services) developed a set of standards adopting a coordination model. This was developed as an alternative to Gold Standards Framework. The standards support the delivery of high quality end of life care in the care home setting; ensuring people living in a care home with ANY condition (including older frail and illnesses other than cancer) will receive the best quality care in the last 12 months of life. These standards have been developed to reflect national end of life publications and to ensure local recommendations are aligned with national guidance. Set of six standards mapped against EoL care strategy quality markers for care homes and National EoL Care programme's route to success for care homes. Furthermore, they complement the locally-owned document supportive and palliative care standards for end of life in the primary care setting and compliment the MPET funded training programme with care home staff. Process:

Care Home agrees to participate and nominates key worker(s)

Baseline self assessment completed

Identify areas for improvement/change

Interim review and supported development of an action plan

Period to implement improvement/change.

Collection of evidence to support changes

Verification/accreditation.
Deciding right – the UKs first regional integration of advance care decisions
Authors: Regnard Claud
Published: March 2012

The need for clear decisions and protocols during emergencies has to be balanced against the need to make decisions that avoid unnecessary or distressing treatment. A regional initiative has the potential to centre decisions on the individual rather than the organisation. The challenge is to ensure that individuals and carers make informed choices, and that the decisions are communicated efficiently and effectively. The North East SHA Deciding Right initiative provides the principles by which all health organisations can set their policies to encourage this partnership around care decisions made in advance for people who may lose capacity in the future. These principles • Centre care decisions on the individual rather than the organisation • Strongly endorse the partnership between the patient, carer or parent and the clinician • Are based on the 2005 Mental Capacity Act and the latest national guidelines on advance care planning • Recognise the individual with capacity as key to making care decisions in advance • Identify the triggers for making care decisions in advance • Create regional documentation for use in any setting that is recognisable by all health and social care professionals. Regional documents have been established for Advance Decisions to Refuse Treatment (ADRT), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Emergency Health Care Plans (EHCPs) • Recognise the Liverpool Care Pathway for the Dying document as a DNACPR order • Minimise the likelihood of unnecessary or unwanted treatment • Introduce Emergency Health Care Plans as an important adjunct in specialist care settings to tailor care to the individual with complex needs • Create principles and documentation suitable for all ages (children, young people and adults) This is the first regional initiative in the UK to integrate the principles of making care decisions in advance for children, young people and adults.
Developing a rapid discharge pathway for end of life care
Authors: Ball Patrick , Mason Louise
Published: March 2012

Background

Achieving preferred place of care at end of life is a core component to national and local end of life care strategy. The specialist palliative care team at Brighton and Sussex Universities Hospitals NHS Trust introduced a pilot document and process to facilitate the discharge of patients in the final days of life. There were no formal audit process of the discharge process prior to introduction of the dedicated pathway but there were numerous complaints and feedback from patients, carers and professionals that the usual discharge process was not responsive enough for end of life care patients.

Pathway

A work stream group of the Trust's end of life care development group was set up with relevant stakeholders and a pathway created to identify and clarify keys steps in successful discharge. One of the main features of our pathway is it is multi-discipline and highlights each individuals role for example, ward nurse and doctor, discharge co-ordinator and members of specialist palliative care. The pathway serves as key co-ordinating document.

Pilot

In November 2011, two wards were piloted between the trusts two hospitals for 3 months. This was then extended in another ward for a further 2 months to provide more data. The Rapid Discharge Pathway was used in addition to the usual discharge documentation when a patient thought to be in the final days of life was being discharged to their home or care home with nursing.

Results

Twenty-one patients were initiated on the rapid discharge pathway; of these 17 (81%) were successfully discharged to preferred place of care (11 home; 6 to Nursing home). Four patients died prior to discharge, three rapidly declined during the process and in the other difficulties arose in deciding preferred place of care. The pathway is now being rolled out across the Trust.
Comparison of conservative management and renal replacement therapy in the Elderly with CKD stage 5
Authors: Hussain Jamilla , Russon Lynne , Mooney Andrew
Published: March 2012

Background

There is limited data on the outcomes of older patients with chronic kidney disease (CKD) stage 5 undergoing renal replacement therapies (RRT) or conservative management (CM).

Aims

Through conducting the largest study in patients over 70 years old we aimed to establish key factors influencing survival and quality of life of patients who chose either RRT or CM at CKD stage 5. This information is essential to ensure patients and professionals can make informed decisions regarding management in such complex cases.

Methods

A retrospective observational survival study comparing both groups was conducted.

Results

441 patients were included (172 CM, 269 RRT). The RRT group survived for longer when survival was taken from the time GFR <20 ml/min (p<0.001). This remained the case when survival was calculated from GFR 15ml/min (p=0.02) and 12 ml/min (p=0.02). However when stratified for age (greater than 80 years old), Charlson comorbidity score (greater than 8) and WHO performance score (greater than 2) RRT no longer had a statistically significant survival advantage. In terms of quality of life, the RR of an acute hospital admission comparing RRT to CM was 1.6, p<0.05, 95% CI (1.14 to 2.13). 47% of CM patients died in hospital, in comparison the Renal Registry states 69% of RRT patients die in hospital. The CM group also had greater access to specialist palliative care (SPC) resources. 131 CM patients accessed community SPC services versus 0 RRT patients. 85% of CM patients had a SPC consultant review versus 4% of RRT patients.

Conclusion

For patients over 80 years old, with high comorbidity scores and low performance status RRT did not offer a survival advantage over CM. Additionally, through accessing a dedicated CM pathway patients have greater access to SPC services and are less likely to be acutely admitted to or die in hospital.
Getting to the other side: improving palliative care transfers from a tertiary cancer centre
Authors: Noble Agnes , Coackley Alison , Griffiths Ann , Howarth Susan
Published: March 2012

Background

A syringe pump is a portable battery-powered device used to deliver a Continuous Subcutaneous Infusion (CSCI), and is used in the delivery of subcutaneous medication to patients in order to optimise symptom control. A tertiary cancer centre can experience huge challenges when transferring patients to alternative care settings as the distances to be covered can be great, and the time taken for the patient to travel can be considerable. At Clatterbridge Centre for Oncology, the system for transferring patients receiving medication via a CSCI was inadequate, as the CSCI would be discontinued and the patient's symptom management could be compromised during the journey. This is especially important during end of life care when a patient is being discharged in the final few days of life.

Aim

To develop a process where patients could be transferred to an alternative care setting with a pump in situ in order to maintain an optimum degree of symptom control during the patient's transfer, with no disruption to medication delivery.

Method

Five pumps were designated specifically as transfer pumps. Documentation was designed to track the pumps and to monitor their return. A padded addressed envelope is sent with the pump for return, with accompanying details for the receiving healthcare professional regarding discontinuing the pump.

Results

Syringe pumps were used for the transfer of palliative care patients on 42 occasions, with 6 being used for patients who were on a rapid discharge home for the dying patient pathway. All patients suffered no disruption to medication delivery.

Conclusion

This innovative system of transferring patients with a syringe pump in situ to maintain an optimum degree of symptom control has been very successful. Staff found the process easy to use, and there was significant benefit to patients.
Lost in translation? Madrid Integrated Palliative Unit
Authors: Merino Teresa García-Baquero , Martínez-Cruz Belen , Ruiz-López Diego , Terrón-Barbosa Raquel
Published: March 2012

Background

Developing and implementing an effective palliative care programme is a strategic priority. Madrid's first PC Unit opened in 1991, within mainstream heath system. 2005 saw an important impulse to PC Teams for a 6.5 m population. 2008–2010 was a period during which to consolidate and develop PC with a strategic plan to stress appropriately trained multidisciplinary teams, robust organisative and clinical models.

Aim

To assess whether Madrid's interpretation of the traditional British model is fit for purpose.

Method

Our model of care (UIMCP), for a population of 1m, incorporates ‘all the services patient and family may need to meet -expertly and timely- their palliative care needs’ with 24 h access to patient's information and uninterrupted access to palliative human and structural resources and collaboration from Primary Care, Hospitals, Independent sector, Patients Liaison Services and Information Systems under Palliative Care Department leadership. Implementation is gradual due to the huge professional training needs and complex integration of technical systems. Evaluation through structure, process and output indicators, cross sectional assessments is regular. Data are continuously collected, analysed by the Regional PC Observatory.

Results and Conclusions

All A99 (terminal illness), episodes programmed activities and telephone calls are recorded. Several 100 protocols have been created including Adult and Paediatric referral forms, Pain (assessment), nursing plans, SD, out of hours calls. (1) Preliminary data show the effectiveness of a seamless clinical model. (2) 24 h specialist PC makes a huge impact on this population. (3) It achieves strategic regional goals ϖ organising all end of life services and resources ϖ setting all technological advances at the service of its population ϖ offering a seamless, wall-less pc clinical unit. (4) Adapting and translating the British hospice/specialist PC Unit to our own reality seems to be successful but only possible by electronic palliative care records.
Improving support upon discharge from a hospice in-patient unit using a discharge pathway
Authors: Lennon Rebecca , Banks Eileen , Seed Jessica
Published: March 2012

An audit and staff survey, about discharges from our hospice inpatient unit, highlighted areas for improvement; delayed discharges, lack of training and delayed discharge letters. It also showed a lack of understanding around discharge procedures among staff and therefore confidence at moving the process forward. The authors devised a discharge pathway that includes sections for doctors, nurses, physiotherapists, occupational therapists, social workers and carers. The sections contain comprehensive instructions for each role, to ensure we are considering all aspects of the patient's needs. It also helps staff understand what is required of them in the discharge process. The section for carers was created after consultation with a hospice carer support group and produced because the authors wanted to make sure the authors were meeting their needs as well.

A separate pathway is being used for rapid discharges, to account for the different circumstances of such discharges. Within both pathways is a sheet that includes important contact numbers. This is given to the patient on discharge and can be used by the patient, carer or health professional, for information about who is involved in care and provides the preferred priority of care. To improve the length of time it takes to send a discharge letter out, the authors are typing instead of dictating them. The whole process has given us the opportunity to train all our staff, on the discharge process, when the authors implemented it. The discharge pathway has improved staff understanding and confidence in the discharge procedure and therefore our discharges are more robust. The authors still have delayed discharges, but the reasons for these are often out of our control; mainly due to equipment delivery. The discharge pathway now comprehensively covers the needs of a patient being discharged from a hospice inpatient unit, who potentially has unstable disease and therefore needs regular support.
Audit of thromboprophylaxis decision-making at three independent hospice inpatient units
Authors: Powell Amanda , McMunnigal Fiona , Dymond Emma
Published: March 2012

Introduction

Palliative care patients should be considered for thromboprophylaxis, given they are often at risk of thromboembolic events. However many have significant contraindications and therefore decisions require careful consideration of risk/benefit burden.

Aim

To identify how medical staff consider and document decisions regarding thromboprophylaxis in patients admitted to three inpatient units (IPU).

Methodology

Initial retrospective review of medical case notes, examining entries within 48 h of admission. 100 case notes (30–40 from each hospice) were reviewed for patients admitted to IPUs from 01 May 2010. The second cycle prospectively reviewed 150 case notes (50 from each hospice) after implementation of thromboprophylaxis education, guidelines and alteration of admission notes to incorporate a thromboprophylaxis prompt.

Results

Documentation of thromboprophylaxis improved from 15% in cycle 1 to 93% in cycle 2. Nine (53%) and 26 (68%) patients already on anticoagulant treatment, remained on treatment, in cycles 1 and 2 respectively. Eighty-three patients (83%) in cycle 1 were not on anticoagulation treatment compared to 112 patients (75%) in cycle 2. Thromboprophylaxis was initiated in 0% and 11% of these patients in cycles 1 and 2 respectively. In cycle 2, 96 patients did not receive thromboprophylaxis. Reasons were documented in 88 patients. Fourteen patients had more than one reason. Documented reasons were: 29% no indication or not wished, 27% approaching end of life, 17% gastrointestinal bleeding, 8% anaemia, 6% on medication with additional bleeding risk, 5% bleeding other than gastrointestinal, 4% coagulation defects, 2% cerebral bleeding risk and 2% injection site problems.

Discussion

It was clear from cycle 1 that documentation of thromboprophylaxis decisions was poor. Although decisions may have been contemplated, the process was not documented. Education, guidelines and changes to admission notes led to significant improvements in the documentation and transparency of decisions regarding the therapeutic dilemma of thromboprophylaxis in hospice inpatients.
Palliative care provision for those with non-malignant respiratory disease: a literature review
Authors: McVeigh Clare , Porter Sam , Reid Joanne , Hudson Peter , Larkin Philip
Published: March 2012

Background

It is recognised that those suffering from a malignant disease have access to excellent palliative care (PC) provision. It is less clear if the same standards of PC services are available to those with non-malignant respiratory disease (NMRD). There is therefore a need to explore the needs of people suffering from NMRD and their carers.

Objectives

The purpose of this review was to determine the experience that those with NMRD have of current PC provision, and identify gaps and needs that require to be addressed.

Design

A comprehensive search of the literature was undertaken, using key terms, of the following databases; CINAHL Plus, MEDLINE and the Cochrane Database of Systematic Reviews. 622 articles were sourced and inclusion and exclusion criteria were applied to highlight the most relevant literature.

Results

22 studies were reviewed using a systematic approach. Five themes emerged from the literature. (1) symptom management – greater PC support is needed. (2) palliative care provision – patients with NMRD have the same palliative care needs as those with MRD, however they do not receive the same standard of PC service provision. (3) health service provision – there is inadequate PC health service provision for those with NMRD. (4) family care givers – family care givers of NMRD sufferers have a range of unmet needs. (5) communication and information – lack of information can lead to anxiety and fear for their future.

Conclusion

Palliative care is required by all those suffering from complex and persistent symptoms resulting from a non-curative illness. Those suffering from a non-malignant disease are not having their needs recognised effectively and therefore not receiving the appropriate palliative health service provision. Further research is required into the palliative healthcare provision available to those with NMRD. This research is currently being carried out by the author.
Electronic palliative care co-ordination systems improve information provided to out of hours teams
Authors: Smith Clare , Hough Libby , Whitmore David , Cheung ChiChi , Riley Julia
Published: March 2012

The UK Department of Health (DOH) End-of-life care strategy advocates Electronic Palliative Care Coordination Systems (EPCCS) to improve communication across providers in acute and community sectors 24 h a day. The Royal Marsden NHS Foundation Trust was an EPCCS pilot site. This audit compares the information available to the London Ambulance Service (LAS) on the EPCCS to the information previously provided by a faxed paper form.

Aim

To determine if the EPCCS improved the quality of the information shared.

Methods

Faxed Palliative Care Handover Forms (PCHF) held at LAS at one time point prior to EPPCS were compared to all EPPCS entries 10 months after implementation.

Results

When comparing the PCHF to the EPPCS, the average age of patients (78 years) remained the same. The proportion of patients with a diagnosis other than cancer increased (33% PCHF vs 48% EPPCS) and the number of GPs completing information increased using EPCCS (29% PCHF vs 39%). Consent improved with consent evident on 49% of PCHFs and mandatory (100%) on EPCCS. The EPCCS was designed with mandatory fields leading to improvements in data completion of the following; • ‘Has the patient been prescribed strong opioids?’ 85.1% (n=135) PCHF vs 100% (n=145) EPCCS • ‘Has resuscitation been discussed with the patient?’ 64.9% (n=100) PCHF vs 100% (n=145) EPCCS, • ‘Has resuscitation been discussed with the carer?’ 66.9% (n=103) PCHF versus 100% (n=145) EPCCS. EPCCS also improved completeness of non-mandatory fields; • ‘Is there a signed Do Not Attempt Resuscitate form in the house?’ (91% vs 77.9%), • ‘Are there emergency drugs left in the home?’ (95.2% vs 50%), • ‘Is death anticipated?’ (96.6% vs 85.1%).

Conclusion

EPCCS does improve data quality covering aspects of care including resuscitation and the end of life phase. This provides support for EPCCS on a wider scale.
Further development of the rapid discharge integrated care pathway (RDICP) hospital to home
Authors: Gambles Maureen , Cannell Lynne , Curie Deborah Murph Marie
Published: March 2012

The ‘rapid discharge pathway’ (RDICP) was developed by the Palliative Care Team at the Royal and Broadgreen University Hospitals NHS Trust (RLBUHT) in response to an identified clinical need to enable imminently dying patients to die in their place of choice. The original RDICP was reviewed and refined in line with Version 12 of the generic LCP. Stakeholder meetings were held to gain consensus and to overcome bottlenecks/blockages in the system and the RDICP was launched in April 2008.

Aim

To undertake an audit of the first year of use of the amended pathway. An audit of outcomes for all 31 patients in 2008/9 who were transferred home supported by the RDICP was undertaken. The RDICP was used on 21 wards, within 5 directorates General Medicine (20) Care of the Older (2) Haematology (2) General Surgery (5) Renal Unit (2). Twenty-one patients had a diagnosis of cancer 61% were Male Mean time from discharge to death=8 days; median 5 days; IQR 2–10 days. No patients were re-admitted to the hospital prior to their death. The RDICP provides a structured and coordinated process to enable a dying patient to go home to die. It is crucial to the success of the framework that specialist palliative care services take a lead role in the use of this pathway. While numbers are small, the authors feel that this framework could be utilised by other health providers with local networking to achieve a rapid discharge of a patient to enable a home death. The RDICP is one means of facilitating choice at the end of life helping to ensure optimum care for dying patients and their families. However, while District Nurses support this process, families have to agree to provide the main bulk of care.
Treatment escalation plans – a tool to aid end of life decision making?
Authors: Paes Paul , O'Neill Cate
Published: March 2012

Background

The number of patients dying in hospital continues to remain high. One of the challenges in combating this is deciding when to actively manage a patient and when to withhold/withdraw treatment. Advance Care Planning concentrates on patient-driven decisions, planning ahead in case they lose capacity to make decisions. Less attention has focused on clinician-led decisions, especially anticipating problems and planning for clinical deteriorations. Treatment escalation planning is one mechanism of planning the care of a patient at risk of deteriorating.

Method

Treatment escalation planning was introduced as a pilot in the following settings in a general hospital: Respiratory, Cardiology, Care of the Older, Medical Assessment Unit/General Medicine, Critical Care and Palliative Care. Audits were carried out in each setting, looking at decision making, before and after the pilot were carried out. The outcomes were measured and feedback obtained from staff in relation to ease of use, issues encountered and practicalities.

Results

The use of Treatment Escalation Plans was popular with junior doctors, especially out of hours. Advantages of using the plans included: creating a culture of thinking ahead, a simple format, and in a few cases patient decisions were affected by the plans. Disadvantages were that most patients during their admission did not need the plans created; the decision making and communication of decisions took extra time.

Conclusion

Treatment Escalation Planning is a potentially powerful tool in trying to deliver appropriate levels of patient treatment. Dilemmas arising from this study include whether to implement this process for all patients (most will not benefit) or for a selected group (at present the authors are not good at predicting patients who will deteriorate acutely). In addition, it raised a number of ethical questions around the communication of decision making, and the level of patient involvement in clinical decision making.
Introduction of county-wide electronic palliative care notes system improves quality and efficiency
Authors: Heron Nicola
Published: March 2012

Background

A partnership of the five different Specialist Palliative Care service providers in Worcestershire came together to implement a county-wide clinical notes system for specialist palliative care patients. The SystmOne electronic clinical management system was introduced in August 2009 across all settings from acute hospital to independent sector hospice and NHS community palliative care providers.

Aims of this survey

To demonstrate improvements in clinical care and efficiency through sector wide access to a single set of electronic palliative care notes.

Methods

Referrals to a hospital palliative care team over 1 month analysed in SystmOne to document patient pathways and access to multiple services and providers. Estimates of time saved by reduced telephone calls and faxes between agencies were also made.

Results

Seventy-two episodes of patient care were analysed. 27 (37.5%) were already known to palliative care services within Worcestershire, therefore clinical information, some advance care planning information and psychosocial details were available to the acute hospital palliative care team at the time of their initial assessment. Thirty-seven (51%) were discharged from the acute hospital and received on-going support from palliative care teams within the county (18 different teams in total), all of whom were able to access the clinical information contributed to the electronic record during the inpatient admission. During this 30 day period, the authors estimate that 17.3 h were saved by communicating/referring via SystemOne. The authors include a case study which demonstrates improved quality of patient care.

Conclusion

County-wide access to a single electronic palliative care record has improved efficiency and quality of information and patient care.
Location, location, location
Authors: Whyte Graham , Groves Karen , Finnegan Clare , Lancs West , Leonard Niall , Scott Helen
Published: March 2012

Background

The End of Life Care Strategy (2008) highlighted the need to raise the quality of care provided to dying people in care homes and this is supported by The Route to Success in End of Life Care – Achieving Quality in Care Homes. (2010) Previous work done locally had suggested there were a large number of attendances at Accident and Emergency (A+E) by care home residents and in order to understand whether any of these were avoidable and form conclusions as to how support for staff caring for these patients could be improved, a greater understanding of what happened at the care home prior to transfer to hospital was felt to be needed.

Aim

To conduct a prospective audit of all A+E and Emergency Admission Unit (EAU) attendances by care home patients at the end of life.

Methodology

Care home patients presenting to A+E and EAU were identified on a daily basis over a 2 month period. Baseline data was collected from the time of arrival to A+E or MAU. Telephone consultations then took place with the care homes in question to obtain information about what happened to the patient leading to the resultant transfer to hospital.

Results

Results demonstrated the extent of coordinated care, review by community clinicians prior to transfer and also the use of end of life tools such as the GSF.

Conclusion

Service improvement initiatives have been targeted to reduce hospitalisation by admission avoidance, further develop the use of end of life tools in care homes, increase the confidence and expertise of care home staff, with the ultimate aim of improving the experience, co-ordination and quality of care that care home residents receive at the end of life.
Development of a non-pharmacological breathlessness management pathway
Authors: Acreman Susan , Baker Kate , Clifton Sian
Published: March 2012

Aim

Breathlessness is one the most common problems experienced in cancer; evidence suggests that up to 79% will encounter this distressing symptom, which can undermine functional ability and compromise independence. Evidence suggests that while there are breathlessness management programmes, few exist specifically for cancer and none provided care and advice cross the eight domains which are physical, psychological, practical, nutritional, social, spiritual, financial and information.

Method

A survey of breathlessness programmes for people with cancer across South East Wales revealed inadequate provision, with current services unable to meet the demand. Additionally, they did not cover the eight domains of care necessary for the provision of holistic care. An evidence based non-pharmacological breathlessness management programme was developed as well as a workforce education programme to ensure the right level of skills and competence of those delivering the pathway.

Results

Fourty people were referred and 22 were seen. The most common presenting tumour sites were breast (N=12), lung (N=9), pancreas (N=3) and ovary (N=3). Of the patients who entered the pathway, 19 (83%) self-managed successfully and 3 (17%) required referral for specialist care such as nutrition, occupational therapy and physiotherapy.

Conclusions and discussion

While dyspnoea is not routinely assessed and is an expected burden for many people with cancer, simple self-management techniques used as this pathway can empower such people to cope a little better with the distress and life limiting effects of their dyspnoea. As this is a patient led intervention, they determine what level of advice and information they want and thus they are able to control this as well as the level of professional intervention accessed. Finally, though the pathway was developed primarily for people with cancer, it has been shown that it can be effortlessly transferred to other conditions where breathing may be compromised.
Management of hypercalcaemia at hospice setting
Authors: Hanchanale Sarika , Jordan Alice
Published: March 2012

Objective

Hypercalcaemia of malignancy is a palliative care emergency that needs early intervention. Bisphosphonate therapy improves the morbidity of acute hypercalcaemia, reduce bone pain and pathological fractures. North of England Cancer Network Palliative Care Guidelines suggests early admission, rehydration followed by bisphosphonate therapy (if appropriate). We assessed the hypercalcaemia management at hospice setting and adherence to regional guidelines.

Materials and methods

Retrospective data of all patients admitted with hypercalcaemia at Hartlepool hospice (January 2010–December 2010) was collected with regard to baseline demographics, calcium level, management and follow-up planning. Further analysis was done to assess whether regional guidelines were followed.

Results

A total of 22 patients were admitted with hypercalcaemia during the study period. Median age (range) was 68 (52–84) years and Male to female ratio was 1:1. The top five common cancers were lung (5), breast (5), prostate (3), bowel (3) and head and neck (2). Patients with mild (2.6–3.0 mmol/l), moderate (3.0–3.5 mmol/l) and severe (>3.5 mmol/l) hypercalcaemia were 18, 3 and 1 respectively. Most common presenting symptom was pain (36%) and nausea (36%). Symptomatic hypercalcaemia was treated in 88% of patients. Intravenous fluid therapy was given in 65% of patients with symptoms. Bisphosphonate therapy was given in 88% of patients with symptoms and after intravenous fluids in 27% of patients. Symptomatic improvement is noted in 56% of patients. Post-treatment calcium level was checked in 70% of patients. Recommendations were intravenous fluid therapy with 1–2 l normal saline to be given before Zolendronic acid (if not contraindicated). Repeat calcium levels at 5 days and 3 weeks. Furthermore, strict documentation of all events including symptomatic improvement was recommended.

Conclusion

Hypercalcaemia in palliative care setting is a common problem and must be treated according to the standard regional guidelines. Follow-up audit has been planned after implementation of recommendations.
Audit of venous thromboembolism risk for patients admitted to a palliative care inpatient unit
Authors: McKenna Maria , Porteous Anna , Andrew Inga , Robson Peter , Lee Mark
Published: March 2012

Background

A venous thromboembolism (VTE) risk assessment tool has been developed locally, in line with NICE guidelines, based upon the National Risk Assessment Model (DoH 2010). This single page document identifies key risk factors for VTE and contraindications to anticoagulation.

Aims

Undertake a baseline audit of the new VTE risk assessment tool within a palliative care setting. Methods: Retrospective case note review of consecutive hospice admissions over a 3 month period, following introduction of the VTE risk assessment.

Results

Forms – 58 patients were admitted during this period, 88% percent had a fully completed VTE risk assessment. Primary prophylaxis – 5 patients (9%) received primary prophylaxis with Low Molecular Weight Heparin (LMWH). The most common thrombotic risks, other than temporarily reduced mobility, were age>60y (64%) and abdominal/pelvic pathology (26%). Twenty-six patients (45%) had a contraindication to anticoagulation, the most frequent being active bleeding (16%) and cerebral tumour (12%). Secondary prophylaxis – Eight (14%) were already anticoagulated for thromboembolic disease, five with LMWH, two with warfarin and one was switched from warfarin to LMWH on admission. Malignant versus non-malignant disease – 51 patients (88%) had a malignancy. None of the seven patients without cancer received primary or secondary prophylaxis. 11% of patients with malignancy were dehydrated, 9% were obese and 16% had a history of VTE. These risk factors were not present in the non-malignant group.

Discussion

Our rates of prescribing primary prophylaxis are higher than previously published data, despite similar contraindication rates. Interestingly, certain risk factors (dehydration, obesity, history of VTE) were more prevalent in the malignant patient group, despite not being cancer specific. This work reiterates that malignancy is a greater risk factor for VTE than immobility.

Conclusion

Use of local, concise VTE risk assessment forms has led to high rates of compliance with guidance. Data collection is on-going.
An audit on ‘death rattle’ (noisy breathing at the end of life), and usage of antisecretory medicat
Authors: Thirukumaran Thiru , Subramaniam Sivakumar , Cawley Declan , Fisher Simon
Published: March 2012

‘Noisy breathing’ also known as death rattle, is common in end of life care situations and can be distressing for the family given it's unpleasant resonance. A recent Cochrane review by Weeet al(2009 review) concluded that there is no evidence to show any intervention was superior to placebo; it is very difficult to subsequently manage.

Aim

To evaluate current practice against national guidelines on the use of antisecretory medications in end of life care.

Methodology

Retrospective, case notes review of all the patients died in the author's unit (Jan 2011–May 2011).

Results

Seventy-two patients were identified with 65 patients having antisecretory drugs prescribed and 36 patients requiring medications. 49/65 had complied with the recommended guidance with only 29/36 having a documentation of a response. 7/36 patients with no documentation of assessment. 24/29 patients had documented benefit from the antisecretory drug and a syringe driver started in 24/36 cases. Apart from drugs evidence of other modalities used was lacking: 3/36 patients evidence of re-positioning only. Documentation of communication with family was only in 4/36. 22/36 patients died within 48 h from 1st dose of antisecretory given and 16/24 patients died within 24 h of the syringe driver starting.

Conclusion

In a majority of patients medications used appropriately and response assessment completed. However, documentation of communication with family and other approaches needs to be improved. Interestingly when antisecretory drugs were used death ensued within 48 hrs for the majority. Education of all staff members is extremely important along with regular audit.