bluuebunny/crossref_metadata_2025 huggingface dataset:
KNOWLEDGE AND PRACTICE OF PALLIATIVE CARE PROFESSIONALS IN PREVENTION OF PATHOLOGICAL FRACTURE
Authors: Debattista Maria , Khodabukus Andrew F , Reynolds Joanne , Horton Paula , Howarth Susan , Humphries Barbara , Smith Jennifer C
Published: February 2014

Background

Metastatic bone disease (MBD) has a damaging effect on quality of life and pathological fracture can impact on survival in advanced cancer. Patients with breast and prostatic cancer in particular who have bone metastases have a median life expectancy in excess of two years. It is essential that there is identification of patients who may benefit from surgical management that can prevent pathological fracture and its associated morbidity. There is recognition that there is under-referral to orthopaedic surgeons for consideration of palliative surgery and in 2005 guidelines were produced to support clinicians.

Aims

To identify the preferences and actions of doctors and clinical nurse specialists in assessing bone pain in adult patients with advanced cancer compared with the 2005 regional standards and guidelines.

Methods

Two simultaneous surveys were done evaluating self-assessed clinical practice and a retrospective case-note review of assessments made by specialist palliative care teams. These were disseminated across integrated palliative care clinical networks in the North West of England.

Results

38 evaluations of self-assessed clinical practice were completed. 29% were unaware of guidance to support evaluation of MBD and pathological fracture. 66% of participants were unaware of their local lead orthopaedic surgeon for MBD. 69 case note reviews were completed. In the 44 patients not know to have metastatic bone disease at the site of pain 57% did not have an assessment of risk of metastatic disease in keeping with standards. 35 had assessments where risk of pathological fracture could be graded and in 80% of these no risk was documented.

Conclusions

Despite the high frequency of bone pain there is insufficient documentation of risk of MBD and risk of pathological fracture. The results present an opportunity for clinicians to discuss local management options within palliative care services and with orthopaedic surgeons and oncologists.
AN AUDIT OF PALLIATIVE CARE PRACTICES IN THE BRISTOL ROYAL INFIRMARY EMERGENCY DEPARTMENT
Authors: Yeomans Daniel , Veysey Sian
Published: February 2014

Aims

The aim of this audit was to compare current practice in the Emergency Department of the Bristol Royal Infirmary (BRI) to the guidelines set out by the College of Emergency Medicine (CEM, 2012)1

Methodology

Using retrospective analysis of patient notes, this audit asked appropriate questions adapted from the nine CEM criteria. Notes were examined from two groups of patients; those who died within the ED and those who died within 24 hours of ED admission (i.e. they had moved onto a different ward). For the purposes of this report, these will be referred to as Group A and Group B respectively. A sample of 2×25 patients overall was deemed to deliver sufficient transferable results.

Results

Group A (died within the ED)

19/25 families were involved with the care of their relatives

23/25 patients had ceilings of treatment imposed

14/25 patients had completed DNAR forms

23/25 patients had organ transplantation considered

20/25 families had bereavement services offered

0/25 patients had end of life pathways started

Group B (died within 24 hours)

13/25 families were involved with decision making about treatment

10/25 patients had ceilings of treatment imposed within the ED

0/25 patients had end of life pathways started

6/25 patients had completed DNAR forms

Conclusions

This audit shows that the BRI ED is meeting four of the measured indicators, excluding those where it were not applicable, by over 80%. It also raises further questions about the validity of an end of life pathway within the ED environment, and the use of DNAR forms.
THE AYRSHIRE AND ARRAN NURSES WITH SPECIALIST INTEREST IN PALLIATIVE CARE PROJECT: THE ROLE OF THE HOSPICE AS A LEARNING ENVIRONMENT
Authors: Stevens Elaine , Connolly Josaleen , Stevens Irene
Published: February 2014

Living and Dying Well: A National Action Plan for Palliative and End of Life Care in Scotland (Scottish Government 2008) highlighted that optimal palliative care provision was highly dependent on professional carers' knowledge and skills. However, even though nurses that have most contact with dying people and their families their knowledge and skills in palliative care can be poor (Stevens 2009). To improve the quality of palliative care provision in both community and hospital settings NHS Ayrshire & Arran in conjunction with The University of the West of Scotland and Ayrshire Hospice re-modelled an academic palliative care course to provide nurses in key clinical positions with the knowledge and skills to influence and provide optimal palliative care within their own clinical environment. These “Nurses with a Specialist Interest in Palliative Care” undertook a12 week course which involved a blend of online learning and a 30 hour clinical placement within specialist palliative care. The poster will present a short rationale for the project and highlight the selection criteria for the Nurses before presenting the role of the hospice as a learning environment. The usefulness of the placement will be discussed utilising the Nurses' own evaluations as well as the independent evaluation of the project commissioned by the funder of the project Macmillan Cancer Support.
DEVELOPING AN EDUCATIONAL INTERVENTION TO ADDRESS THE DISCREPANCIES IN PRN ‘AS REQUIRED’ PRESCRIPTIONS WITHIN A HOSPICE SETTING
Authors: Cawley Declan
Published: February 2014

Background

Within the current healthcare arena, the identification of risks within organisations and minimising their negative impact on patient care is fundamental. Reports from the national and international literature have identified strong opioids and sedatives as a cause for concern within clinical practice. Recent baseline data identified significant variations in the practice of prescribing and administration of these drugs even within one organisation.

Aims

To develop an educational intervention that is informed by clinical governance practices and utilising current work based assessments to evidence and embed good clinical practice.

Results

A baseline review of PRN ‘as required’ medications identified significant variations in drug dose and escalation, frequency of administration that doesn't match its' pharmacokinetics but importantly inconsistent documentation supporting ‘indication or use’ to guide nursing administration. A document was produced to highlight the issues from the baseline review, detailing the particular areas of concern and what current guidance suggests. In step 1, clinical vignettes were presented with the view of self-completion prior of Step 2. Within Step 2, trainees gave feedback on their rationale for their prescribing and what they actually documented. The case based discussion approach (CbD) was rated as very useful by trainees new to the specialty. A pre-completed sheet with appropriate prescribing and rationale was given to the trainee with useful resources after the discussion.

Conclusions

Within clinical practice, implementation of good practice guidance is fundamental to the success of any audit or baseline review of discrepancies in care. However there is a lack of work based assessments combining guidance, an opportunity for self-completion and then informed feedback so that an individual's learning needs can be appropriately highlighted and subsequently addressed. We believe the principle of this approach has the wider opportunity to tailor the learning needs of the trainee within certain challenging areas of practice.
PALLIATIVE EDUCATION FOR UNDERGRADUATE MEDICAL STUDENTS BASED ON THE NATIONAL SURVEY IN JAPAN
Authors: Tamba Kaichiro
Published: February 2014

Background

Palliative care education for undergraduate medical students has not been well established in Japan. A foundation supported our university to have a department of palliative care medicine for undergraduate palliative education for three years. Fortunately, a nationwide consensus syllabus of palliative medicine for undergraduate medical education had been developed.

Objectives

To reflect the development of curriculum of palliative care for undergraduate.

Materials & Methods

Materials; (1) source of the syllabus, (2) source of teaching materials, (3) teaching staffs and supporters. Methods; evaluation by (1) development of the curriculum, (2) analysis of the budget, (3) analysis of the access of our website with Google analysis®.

Results

(1) Development of the curriculum; Number of the annual classes of palliative care increased from 13, 18, 22, respectively. (2) Analysis of the budget; 66.4% of annual expenditure was personnel expenses, 10.0% for administrative expenses, 6.0% for supplies expenses, 4.1% for travel expenses, 3.9 % for appliances, 9.6% for others. (3) Effect of disclosure of educational resources; the daily access to our website was significantly concentrated just before the national medical practitioners qualifying examination in Japan compared with that after the exam (p<0.0001).

Conclusions

Experienced palliative staffs, total support by the university, moderate financial resource and developed syllabus enabled systematized palliative education for undergraduate medical students. It might propagate related to the national medical practitioners qualifying examination.
IMPACT OF AN EDUCATION PROGRAMME FOR HEALTH PROFESSIONALS ON SUPPORTING PREFERRED PRIORITIES FOR CARE DISCUSSIONS WITH PATIENTS
Authors: Powell Paula , Cummins Janet , Gallagher Lisa , Joyce Anne-Marie
Published: February 2014

Background

This poster describes an audit conducted by the Community Integrated Advance Care Planning Team for St Helens and Knowsley of documentation by patients of their Preferred Priorities for Care and the impact of this on their place of death.

Aim

For St Helens and Knowsley Community Services advance care planning has been a priority since 2009 when a facilitator came into post to support this. A number of education initiatives across both areas have focused on giving health professionals the skills and confidence to support patients in making decisions about their care and documenting them. A robust audit trail has allowed the team to track the Preferred Priorities for Care (PPC) document that is used locally and collate the data on patient's place of death in comparison to their preference.

Results

1007 PPC documents have been completed to date with 659 deaths so far. 1 (0.1%) patient chose hospital as their preferred place of dying. 30 (3%)chose hospice as their first choice 96.9% home or care home (usual place of residence)

The audit has shown that 88% of patients who completed a PPC achieved their preference for place of dying which is significantly above the 40% home/care home deaths in the locality.

The audit has also provided data on which health professionals and settings are completing PPCs and where training can be targeted for the future.

Conclusion

Supporting (through education) health professionals to make advance care plans with patients can have a significant impact on a patient's place of care at the end of their life.
PREPAREDNESS TO CARE IN ADVANCED COPD: HOW PREPARED ARE INFORMAL CARERS OF PATIENTS WITH ADVANCED COPD AND WHAT ARE THEIR SUPPORT NEEDS? BASELINE DATA FROM AN ONGOING LONGITUDINAL STUDY
Authors: Farquhar Morag , Ewing Gail , Moore Caroline , Gardener Carole , Butcher Hanne Holt , White Patrick , Grande Gunn ,   On behalf of Living with Breathlessness study team
Published: February 2014

Background

Chronic obstructive pulmonary disease (COPD) is a chronic progressive condition which, when advanced, can lead to high carer-burden. We lack good research evidence on the needs of informal carers of patients with advanced non-malignant disease and how best to support them; in particular the lack of longitudinal carer research has been noted.

Aims

To describe the preparedness to care among informal carers of patients with advanced COPD and their support needs at the baseline of an ongoing longitudinal study.

Methods

Mixed method baseline interviews with a cohort of approximately 100 informal carers of patients recruited from a primary care population base in the East of England. The cohort forms part of the Living with Breathlessness study and, as such, is being followed over time in a mixed-method 18-month Longitudinal Interview Study involving 3-monthly semi-structured interviews with flexible methodology to capture changing patient function and service access, and carer need and support. Quantitative carer measures include Preparedness for Caregiving Tool and Carers Support Needs Assessment Tool analysed using descriptive statistics. Purposively sampled qualitative data will be analysed using a framework approach and multiple-perspective case study methodology.

Results

At the time of abstract submission baseline data collection is ongoing but due for completion by the end of October 2013. The results will describe the preparedness of informal carers to care and the relationship between preparedness and carer support needs when caring for patients with advanced COPD.

Conclusions

The Living with Breathlessness study aims to provide new evidence on the trajectories of health and social care needs and service access of patients with advanced COPD and their informal carers to inform a new framework for care and support in advanced non-malignant disease.
FORWARD TO THE FUTURE: INTRODUCTION OF ADVANCE CARE PLANNING IN A TERTIARY CANCER CENTRE
Authors: Noble Agnes , Coackley Alison , Griffiths Ann , Howarth Susan
Published: February 2014

Background

Advance Care Planning is a process of discussion with individuals about their wishes and preferences regarding the type of care they would wish to receive or refuse in the future, should they lack capacity at that time. These discussions need to be handled with sensitivity and skill, the outcomes documented and reviewed regularly, and communicated to other relevant people with the individual's consent. The recognition of the importance of Advance Care Planning has been highlighted by the National End of Life Care Programme. As a UK tertiary cancer centre serving a population of 2.3 million, the implementation of Advance Care Planning produced significant and unique challenges.

Aim

To introduce Advance Care Planning into a tertiary cancer centre.

Method

Education was delivered to all health care professionals in both formal and informal sessions, including 'drop in' sessions provided over a whole day. Resource folders were introduced into all wards, containing written information for staff, and localised information and documentations for patients.

Results

There was good attendance from staff across the organisation and the formal sessions stimulated much discussion especially regarding the role of a tertiary centre. These discussions included the inherent difficulties involved in liaising with a range of health care professionals across the region. There are multiple Health Care Teams in the Network, all of whom are at different stages of implementing Advance Care Planning for their patients. It was agreed that sensitive communication with the patient was of the utmost importance, with some staff admitting their lack of confidence in this area.

Conclusions

The introduction of Advanced Care Planning into a tertiary cancer centre is a challenge due to the wide geographical area. Further education sessions are planned including an intermediate experiential two-day communication skills training course to help staff required to initiate sensitive discussions with patients.
ENGAGEMENT WITH PROGNOSTICATION. INCORPORATING THE GOLD STANDARDS FRAMEWORK INTO DISCHARGE PLANNING
Authors: Griffiths Ann , Coackley Alison , Noble Agnes , Howarth Susan , Lee Heather , Hampton-Matthews Julian , Foulkes Margaret
Published: February 2014

Background

The GSF was developed in 2000 to improve palliative care in primary care by improving :- 1. Quality of care 2. Co-ordination and communication 3. Patient outcomes and cost effectiveness.

Acute hospitals have been described as the missing link, providing seamless, co-ordinated high quality End of Life care. Enabling staff to identify patients in the last 12 months of life in a systematic sustainable way and linking this into discharge planning proves difficult.

There has been no experiences in implementing GSF in Tertiary Cancer Centres, this causes many challenges; around communication with multi-disciplinary teams across a large geographical area.

Aim

To improve engagement of staff in identifying patients in the last 12 months of life.

Method

RAG is a tool used for highlighting patients needs, referrals and outcomes to aid in a safe/timely discharge. RAG (Red/Amber/Green) boards have been implemented as part of the discharge planning. It's regarded as a good way of engaging colleagues in the identification of patients within the last twelve months of life.

Results

A weekly meeting is held on all wards. Staff discuss and agree the expected prognosis for individual patients. Each category is linked to specific needs which are addressed.

Blue=Stable disease

Green=Less than twelve months

Amber=Weeks prognosis

Red=Days prognosis

The visual aide memoir assists all health care professionals to review the needs of individual patients ensuring appropriate support is in place for both patients and carers at the time of discharge

Conclusion

The GSF can be linked with the discharge planning process in an acute hospital setting. This facilitates discussion and ensures the needs of patients are addressed and met in a timely manner. Appropriate communication with primary healthcare teams is achieved with collaboration and seamless care across healthcare settings becomes a reality.
TO ESCALATE OR TO PALLIATE? AN AUDIT OF PATIENTS AT RISK OF DETERIORATION ON MEDICAL WARDS
Authors: Grewal Bhajneek , Johnson Fiona
Published: February 2014

Background

Junior doctors are often the first to assess deteriorating patients out of hours. From our experience, many deteriorating patients do not have escalation plans in place from the patient's regular medical team. Making decisions to escalate or palliate unwell patients is therefore made more challenging.

Objectives

The primary objectives of this audit were to identify:

1) If deteriorating patients are recognised by nursing staff on the wards

2) If these patients are assessed promptly and by the appropriate professional

3) If escalation plans exist to guide on call doctors when making management plans for these patients.

Methods

Data was retrospectively collected using a modified audit tool based on NICE 50 (Acutely ill patients in hospital). Patients at risk of deterioration were identified by an Early Warning Score >5. Thirty case notes were examined on several medical wards in Airedale General Hospital.

Results

A doctor or member of the Outreach Team was contacted in 70% of cases when a patient had a high EWS >5 (standard 100%). A third of patients were not reviewed after a high EWS (standard 100%). Only 5 out of 30 patients had a clear escalation plan highlighting whether higher level care was appropriate. Evidence of preventable harm was not found but examples of poor practice were identified e.g. patients with palliative conditions in whom DNACPR had not been considered.

Discussion

The results were presented orally to clinical staff and in the hospital newsletter to raise awareness of the need to make improvements. A distinctive Escalation Plan form and sticker was designed and is being piloted on the medical wards to encourage 'Day' teams to state a ceiling of care. Feedback will be obtained from staff when re-audit takes place.

Conclusion

Assessment and management of deteriorating patients must be improved. With the above interventions we hope to show that this can be achieved in the DGH setting.
DOCUMENTATION OF RESUSCITATION DECISIONS IN AN SPECIALIST PALLIATIVE CARE IN-PATIENT UNIT
Authors: Strubbe Patricia , Millar Jane , Haddock Claire , Redmond Lottie
Published: February 2014

Background

We are based in what was the South Central Health Authority which introduced a Unified DNACPR (Do Not Attempt Cardio Pulmonary Resuscitation) policy and document (lilac form). This enabled the transfer of DNACPR decisions across different settings. This document is still recognised since the introduction of the clinical commissioning groups. When patients are admitted to an in-patient Palliative Care unit we make a decision about the patient's resuscitation and transfer (to an acute hospital in case of sudden acute deterioration) status. We document whether the patient/ carer has been informed and review the decision weekly. We also document whether a patient brought in a lilac form on admission. On discharge we offer the patients who were DNACPR during, but not prior to admission, the opportunity to ‘own’ the DNACPR decision by offering them to take the lilac form home. All the above is communicated to the clinicians in the discharge letter.

Aims of the audit

We did 2 retrospective audits of 40 consecutive set of notes to assess the completion of the resuscitation documentation and whether this information is documented on the discharge letter sent to GP and other clinicians involved in the patient's care.

Results

We will present the results of the first audit which showed a fairly good compliance both in filling in the resuscitation and transfer documentation in the notes and the documentation in the discharge letters. Specific recommendations were made about the documentation, timing of review of the decisions and on when to offer patients, who did not have a lilac form prior to admission but were DNACPR during admission, the option of taking a lilac form home on discharge. The results of the re-audit will be presented and whether the recommendations improved decision making and communication with patients, carers and professionals.
DEMOGRAPHIC AND HEALTH PROFILES OF PATIENTS SEEN BY PALLIATIVE CARE ADVANCED PRACTICE NURSE IN SONGKHLA HOSPITAL, THAILAND
Authors: Sae-Chit Kallaya , Nilmanat Kittikorn
Published: February 2014

Background

Palliative care services in Thailand had been gradually developed. However, little is known about services provided.

Objectives

This retrospective study was aimed to describe demographic and medical and health profiles of patients seen by a palliative care advanced practice nurse in Songkhla hospital.

Materials & Methods

All patients who were referred to a palliative care advanced practice nurse at Songkhla hospital were identified and recruited. Palliative Care nursing records for these patients were reviewed and analysed for various demographic data, medical diagnosis and treatment information and patients' awareness of their health status and treatments plan.

Results

A total of 98 records were deem suitable for analysis. 57.1% (56) were male. The vast majority of subjects was Buddhist (84.7%). A mean age was 63.6. Over half of the subjects had PPS in range 40 – 60(53.1%) and cancer diagnosis (58.2). Top three medication received during hospitalization included antibiotic drug (67.35%), sedative drugs (32.65%), and analgesic drugs (27.55%). Majority of samples received feeding byNG tubeas current intervention. Dyspnea, fatigue, and pain were commonly reported as the most concerned symptom. 53.1% of patients were aware of their terminal diagnosis. An end of life decisions were discussed with 21.4% of patients and with 59.2% of family members. Discharge condition included clinically improved (41.8%), death (36.7%), refusal of further treatments (20.4%) and referral (1.1%).

Conclusions

The findings provide a picture of patient characteristics and medical profiles. The results will be useful for health professional to develop palliative care services.
RELEVANCE OF CANADIAN HEALTH CARE EVALUATION PROJECT (CANHELP) QUESTIONNAIRE FOR PATIENTS ON HOMECARE IN MUMBAI
Authors: Ghoshal Arunangshu , Dighe Manjiri , Deodhar Jayita , Dhiliwal Sunil , Damani Anuja , Muckaden Mary Ann
Published: February 2014

Background

The Palliative Care unit at Tata Memorial Hospital has a multidisciplinary home care team serving Mumbai based population for over a decade.

Objective

Study the relevance of Canadian Health Care Evaluation Project (CANHELP) questionnaire in Mumbai based patients and families registered with Palliative Medicine Department, Tata Memorial Centre who are being presently provided with homecare services and to identify unmet needs of care provided at end-of-life.

Methods

CANHELP Questionnaire assesses importance of end of life care provision and satisfaction derived, on a scale of 1–5 (ascending scale).There are 38 patient centred questions and 40 family questions/per unit; divided into subscales by authors. In this cross-sectional IRB approved study, the CANHELP questionnaire was served on 20 such patients and their families from September to November 2012 after taking informed consent in their preferred language. Data were collected and analyzed using SPSS.

Conclusions

The mean value calculated for Importance reflects that both the patients and families found end of life care provision to be very important and the CANHELP questionnaire to be relevant. Satisfaction reflects that both groups were somewhat satisfied with end of life care services provided.

The families were somewhat satisfied with their own involvement in care at the end of life for their patients. They feel that they can contribute more towards it. The patients were not very satisfied with their participation in deciding the care process at the end of life. A closer look reveals that this is particularly regarding discussions with doctor about the place of management and the use of life sustaining technologies at the end of life and there is a need for further discussions regarding this.
END OF LIFE CARE CHAMPIONS—A PARTNERSHIP APPROACH TO DEVELOPING TRANSFORMATIONAL LEADERS IN THE ACUTE SECTOR
Authors: Sweetland Caroline , Drabble Tess , Walford Carole
Published: February 2014

Aims

Ahead of the Frances report (2012), the acute and third sector in West Dorset collaborated to drive through improvements in end of life care in Dorset County Hospital Foundation Trust (DCHFT). The project aimed to: Increase the focus on dignified care to the frail and elderly in DCHFT Develop End of Life Care Champions as transformational leaders (Krause 2007): influencing, motivating, and inspiring their colleagues through their End of Life Care practice.

Structure

The project had 2 main elements: The support of End of Life Care Champions identified from each ward Delivery of 12 multi-professional study days on communication skills, endorsed by Bournemouth University and 6 Royal College of Physicians CPD points. Weldmar Hospicecare Trust delivered two programmes (registered/non-registered) of 3 study days. Content was drawn from the EoLC competencies, Routes to Success publication; focussing on: rapid discharge from hospital communication resuscitation orders Liverpool Care Pathway. Delivery included Support to disseminate knowledge e-learning. Presentations from GSF Beacon accredited care homes. ‘Learning in practice’ day in varied settings : hospice, funeral directors, local care homes.

Results

Joint longitudinal analysis is in early stages, initial anecdotal evidence is positive: improvement in effectiveness of rapid discharges; increased written compliments and reduction in complaints relating to end of life care. The EoLC Champions themselves expressed increased confidence in: talking with patients/families regarding death and dying advocating with senior clinicians. sharing knowledge through: EoLC notice boards, information folders, teaching and launch of ‘Back of the Door poster project’. The communication study days have been equally positive: participants valuing experiential teaching techniques.

Conclusion

The project strengthened partnership between the hospital and hospice, from collaboration on the bid to full support from clinical leaders and management. Future plans are to embed knowledge and skills and then support the champions through action learning groups.
INITIATING DISCUSSION IN END OF LIFE CARE: CLINICIAN'S PERSPECTIVES
Authors: Jones Kerry , Baines Rebecca , Lang Iain
Published: February 2014

Background and Aims

Engaging patients nearing the end of life in discussion about their subsequent treatment is regarded as a vital aspect to the provision of effective and cost-effective palliative care (Department of Health, 2011; National Institute of Clinical Excellence, 2012). There is little research to date which suggests how such discussions can be easier to initiate or how clinicians can optimise their communication with patients and their families on end of life care.

These issues are typically addressed using Advance Care Plans such as the Liverpool Care Pathway or a locally developed Treatment Escalation Plan (TEP) and a multi professional framework for the delivery of compassionate care in the last hours and days of life. The TEP was developed in response to variability in care planning and the lack of patient and carer involvement in it.

In this paper, I discuss clinician's accounts of the barriers and facilitators to initiating conversations about advanced care planning at the end of life with patients and their families and their approaches to overcoming these challenges.

Methods and Results

Data collected from 20 qualitative in-depth interviews with Palliative Care Consultants and other senior clinician's in a hospice and hospital environment show that several domains were identified as vital to the provision of a compassionate approach to end of life care. These include, developing a trusting and ongoing relationship with both the patient and family members, adopting a multi disciplinary approach, engaging in opportunistic and ongoing discussions concerning malignant and non-malignant disease.

Clinicians who engaged patients and their families in multiple conversations about their needs and treatments, and who sought to include psychological, social as well as biomedical aspects of care, report providing this aspect of end of life care as integral to providing compassionate care at the end of life.
IMPROVING END OF LIFE CARE (EOLC) THROUGH INNOVATIVE WORKING
Authors: Bailey Fiona , Dargan Susan , Hill Rachel , Quinn Barry
Published: February 2014

Background

As part of improving EoLC at Ashford and St Peter's NHS Foundation Trust (ASPH), the Trust collaborated with Woking and Sam Beare Hospices (WSBH) to increase access to hospice beds for patients who might not traditionally have been considered for referral, by contracting 2 EoLC beds at the hospice.

Aims

improve the end of life care experience

support patient choice around preferred place of care/death

promote earlier identification

seamless service delivering EOLC

Methodology

Hospital and Hospice staff developed an agreed pathway. Patients are identified by medical and surgical teams, and then reviewed by the hospital palliative care team, to ensure that the transfer is appropriate and that it's the patient's wish to be admitted to the hospice. The hospital speedily transfers a patient when a bed is available and without a formal referral.

Results

In the pilot period (3.5 months) there were 34 admissions, with 19 of these patients having a non cancer diagnosis. However, 10 patients died in less than 24 hours. Although all relatives reported they were glad that the patient had been transferred, the project team felt that such a short length of stay was unacceptably high and the process was reviewed. During the following 4 months, there were 22 admissions with 2 deaths in less than 24 hours. 9 of these patients had a non cancer diagnosis.

Conclusion

This model has helped to increase the awareness of EoLC in ASPH and to promote closer collaboration with the hospice. It has illustrated the challenges of identifying patients at the EoL. The high number of patients dying in less that 24 hours may reflect the need for earlier identification and that in some non malignant conditions, treatment may continue until close to death.
A QUALITATIVE STAFF EVALUATION RE-AUDIT OF THE HOSPITAL SPECIALIST PALLIATIVE CARE TEAM AND EVALUATION OF OUR 7 DAY SERVICE
Authors: Kirton Lea
Published: February 2014

During October 2011 an internal staff questionnaire was designed to gain feedback on the hospital specialist palliative care team from selected nursing groups, junior doctors and consultants. The aim was to gain feedback on the impact and effectiveness of the specialist palliative care service.

A majority of the responses were positive in the impact the service has had on patient care.

Key learning points were the need to continue to raise the profile of the palliative care team, to ensure all areas have access to our availability and how to contact us, and the need for continued/rolling education for all disciplines of staff.

There are currently 17 acute hospital trusts in the East of England with specialist palliative care teams, 5 of which (including Colchester Hospital University Foundation Trust) offer a 7 day service.

CHUFT specialist palliative care teams 7 day service commenced in October 2010. The team covers 24 adult wards across 2 sites.

The aim of this piece of work is to re-audit staffs evaluation of the service, and to look at referrals received by the service from October 2012-June 2013, with particular reference to the weekend service provision and effectiveness of this.
PROLONGED DWINDLING CHARACTERISES THE ILLNESS TRAJECTORY OF NURSING HOME RESIDENTS AT THE END OF LIFE
Authors: Finucane Anne , Stevenson Barbara , Murray Scott
Published: February 2014

Background

Three trajectories of physical decline have been identified towards the end of life: (i) a short period of evident decline typically experienced by patients with cancer; (ii) long term limitations with intermittent serious episodes typically experienced by patients with organ failure; and (iii) prolonged dwindling typically experienced by patients with frailty or dementia. An understanding of these trajectories will facilitate anticipatory care planning and decision-making as end-of-life approaches.

Aim

To determine the dominant illness trajectories of nursing care home residents, and to explore multimorbidities in this patient group.

Method

We collected data as part of a larger project to improve palliative care in South Edinburgh care homes. Eight participating care homes completed an after death audit form for the last ten residents who died prior to the project starting. This included their cause of death and main and other diagnoses.

Results

Data on 77 residents was reviewed. The illness trajectory of 90% of residents was characterised by prolonged dwindling, although 30% of residents experienced mixed illness trajectories. About half of those with a mixed trajectory experienced dementia and cancer while half experienced dementia and organ failure. 67% of residents experienced two or more chronic morbidities. Overall, 78% had dementia.

Conclusion

Nine out of ten nursing home residents experienced prolonged dwindling prior to death. Most had multiple morbidities and high symptom burden. Traditionally palliative care services have been modelled on the needs of patients with malignant disease. Interventions to improve palliative care in nursing homes need to be modelled on patients who experience prolonged dwindling characterised by dementia.
ADVANCE CARE PLANNING IN PRACTICE
Authors: Harrison Kerry , McGee Helen
Published: February 2014

Background

Advance Care Planning (ACP) is a voluntary process of discussion about future care between an individual and their care providers and is recommended as best practice in end of life care.

Hospice in the Weald (HitW) routinely documents patients' ACP in the patient record. This audit was carried out to ascertain what impact this information had on the patients' end of life care.

Aims

To identify how many deceased patients had ACP conversations clearly documented in their record

To explore the content of the information in the notes in a 10% random sample

To look at place of death for these patients and compare with those who didn't have ACP notes

Method

A retrospective audit was performed looking at patients who died between 1/8/2012–29/2/2013. A 10% random sample was identified, of whom half had ACP clearly documented. The notes were read and salient information recorded.

Results

439 patients died during the 7 month period of whom 51% had an identifiable ACP conversation recorded in their notes. 44 notes were looked at and there was a marked difference between the place of death for those with documented ACP and those without (Home 37% vs 22% and Hospital 4% vs 19%). There were many instances where although ACP conversations were taking place they were not recorded in one location and not updated and therefore were not easily accessible to all staff.

Conclusions

This audit confirms that well documented ACP conversations do impact on place of death but that even within a specialised setting, it can be difficult to identify significant ACP discussions and for all staff to be easily aware of them. This has implications for recording and sharing this information between organisations which is recommended best practice. Changes to our recording processes are now in place in an attempt to improve this for the future.
USE OF A TASK AND FINISH GROUP TO IMPROVE CHILDREN'S SUPPORT BEFORE THE DEATH OF A PARENT
Authors: Clipsham Laura , Pickard Jane
Published: February 2014

Background

In January 2013, the support of children aged 18 years and younger with a parent admitted to the hospice was audited. This showed variations in the assessment of children's needs and subsequent discussions within the multidisciplinary team, leading to the formation of a multidisciplinary Task and Finish group to review how this aspect of holistic care can be improved.

Methods

A multidisciplinary group met regularly over a 6 month period. Terms of reference were agreed with the aim of reviewing identification of children's support needs, and seeking ways to improve this. Audit standards for adoption by the hospice were agreed to facilitate ongoing service evaluation.

Results

The group identified a need for the following:

Improved documentation: Weekly MDT meetings are a suitable forum for identifying and discussing concerns. A trial of specific prompts for record of discussions increased the documentation of children's knowledge of their parent's illness and the impact of the illness on children and their family to 100% (previously 28.6% and 71.4% respectively).

Accessible resources for patients and staff: Approval was gained from the Patient Information Group for age-appropriate leaflets to be freely accessible in the hospice, with additional child bereavement resources available if requested. Cushions showing emotions were purchased for the children's play area to improve communication with younger children.

Ongoing review of practice: A steering group was established to continue work focusing on meeting children's bereavement needs.

Conclusions

Introduction of specific prompts to aid documentation of MDT discussions appear to be effective at highlighting the need for additional support for children, whilst still enabling an holistic, individualised approach to patient care. It is recommended that a specific MDT template be developed which incorporates these. The introduction of additional resources and ongoing review by a steering group will facilitate ongoing service development.
SMALL CHANGES, BIG DIFFERENCE: IMPROVEMENTS IN HOSPITAL BEREAVEMENT SERVICES
Authors: Swift Ben
Published: February 2014

Background

In 2010 new staff were employed and formed into a formal joint Mortuary & Bereavement Service for the Trust.

Aims

To develop the service whilst reviewing quality and turnaround time.

Methods

Review of existing facilities and practices revealed many areas ripe for development and this presentation describes how the changes were achieved for an area which remains largely hidden to the rest of the hospital.

Results

A professional looking uniform and investment in staff training and development; rebuilding and modernization of the entire mortuary and bereavement suite (include colour changing lights for skin effects) on two sites; development of a bed cover allowed dignified, respectful transfer of in patients' beds, rather than a concealment trolley, with resulting reduction in manual handling.

Mortuary sessions for hospital staff improved understanding, reduced fear of the unknown, improved communication with families and compliance with care after death procedures. Procedural changes resulted in improved quality of death certification and the resulting documentation presented more professionally and respectfully in specially designed folders with useful information.

Many small touches – quality ‘property bags’ for patients' effects; 'last thoughts, words and wishes' cards; ‘forget me not’ seeded cards; keepsake pebbles; ribbon ties and muslin bags for hair locks; free parking for those collecting certificates have served to improve a difficult experience.

Redesigned, more user-friendly bereavement booklets; staff cards with prompts for discussing tissue donation and departmental cultural awareness posters produced to ensure cultural sensitivity to individual need; support for parents facing the loss of a child and those who have miscarried, ensure burial and cremation facilities are appropriate.

Conclusions

Feedback from patients is collated and used in real time to continue change. This presentation describes the difference this sensitivity and creativity have made to bereaved families' experiences.
ANALYSIS OF DIAMORPHINE DOSES PRESCRIBED FOR PATIENTS RECEIVING ‘JUST IN CASE FOUR CORE DRUGS’ FOR END OF LIFE CARE
Authors: Dickman Andrew , Khoo Grace , Morris Tracey
Published: February 2014

Background

In September 2012, an anticipatory prescribing policy was introduced across the healthcare. The ‘Just in Case Four Core Drugs’ (JiC4CD) policy can support proactive symptom control by promoting anticipatory prescribing, ensuring that common symptoms (for example nausea and vomiting, pain, respiratory secretions and agitation) are responded to in a timely fashion.

The four core drugs have been chosen for the locality because they are consistent with the prescribing algorithms of the local Liverpool Care Pathway. These drugs are diamorphine, glycopyrronium, levomepromazine and midazolam, although alternatives are acceptable should they be necessary (e.g. oxycodone instead of diamorphine). A recent national survey concluded that morphine, not diamorphine, is the most commonly prescribed opioid for administration by continuous subcutaneous infusion. There is a potential cost saving by substituting morphine for diamorphine.

Aims

To analyse the doses of diamorphine prescribed for patients receiving JiC4CD and to determine the feasibility of switching to morphine.

Method

Electronic discharge prescriptions over a 12-month period for JiC4CD were identified. Those prescriptions for diamorphine were analysed to determine the mean, median and mode doses prescribed.

Results

A total of 211 discharge prescriptions for JiC4CD were dispensed by the hospital pharmacy over the 12 month period. There were 193 (91.4%) discharge prescriptions that included diamorphine as the opioid of choice. The mean (4.77 mg), median (5 mg) and mode (5 mg ) doses were determined.

Conclusion

The analysis illustrated that morphine could be considered as an alternative to diamorphine for patients receiving JiC4CD for end-of-life care.
IMPLEMENTATION OF THE AMBER CARE BUNDLE: A WAY TO MANAGE UNCERTAINTY
Authors: Meredith Joanne , Evans Howard
Published: February 2014

Background

Warrington and Halton NHS Foundation Trust is a part of Transforming End of Life Care in Acute Hospitals. The Transform programme advocates the use of tools and enablers to standardise good evidence based care for patients that are nearing end of life. The AMBER care bundle is one of the 5 key enablers, used to support communication with patients and family and promote good planning when recovery is uncertain.

Aim

To Embed the tool through facilitation on selected wards throughout the trust and measure and record the impact on patient care, to continue to improve end of life care, in the acute setting.

To audit the use of the AMBER care bundle in relation to improvement in the length of stay, hospital readmission, coordination of care, medical planning and communication when recovery is uncertain.

Method

A sample audit of notes for inpatients that had died where their care had been supported using the AMBER care bundle. A sample of patients summary care records when patients had been discharged from hospital following a stay where care was supported using the AMBER care bundle.

The audit proforma included quality of the completion of the bundle itself, documentation of Preferred Place of Care, length of stay, communication, decision making and readmission into hospital.

A retrospective audit of case notes for in patients that had died that had not been supported using the AMBER care bundle used as a comparison.

Results

The audit did show that there was a significant difference in quality of documentation, planning and the recording of preferred priorities for care for those patients that had been supported using the AMBER care Bundle, than not.

Health professionals were able to identify the correct patients as suitable for support using the bundle.

Conclusion

The AMBER bundle improved the documentation in patient's case notes of escalation decisions, and the documentation of conversations with patient and or their family at a time of uncertainty.
HOSPICE AT HOME SERVICES—THE IMPORTANCE OF INTEGRATION AND MEDICAL SUPPORT
Authors: Hugel Heino , Gavin Catherine , Mitchell Carol , Edwards Debbie
Published: February 2014

Background

Hospice at home services are an increasingly important part of specialist palliative care support to patients in the community. Most hospice at home services consist of different nursing interventions, but don't include medical support.

Aims

We describe outcome data including a service evaluation of a hospice at home service model that includes full medical support. This service model comprises a nurse lead sitting component, a nurse lead accompanied transfer home, but also consultant lead specialist palliative care medical support for complex clinical situations in patients referred to the service. The service is firmly integrated into a specialist palliative care provider that provides the full spectrum of specialist palliative care including inpatient and outpatient services for the locality.

Results

170 patients were supported by the service in an 18 months period from 1/2012–6/2013. 80 (47%) received a specialist palliative care medical visit as part of their intervention. 135 patients died within the 18 months period. Of these 114 (84%) died in their usual place of residence (100 at home, 14 in a nursing home). Sixteen (12%) died in hospice inpatient unit and only five (4%) died in hospital. A service evaluation was carried out for a ten month period from 1/2012–10/2012. Health care professionals who had referred to the service and families of patients who had used the service were sent questionnaires. Both patients and health care professionals rated the service in general very highly. Particularly health care professionals commented that the medical intervention component had helped to avoid crisis situations and allowed patients to stay at home.

Conclusions

These results suggest that firm integration of hospice at home services into existing specialist palliative care services and medical support including consultant leadership should be key components of this type of service.