bluuebunny/crossref_metadata_2025 huggingface dataset:
Patients' experiences of oxygen therapy and dyspnoea: a qualitative study in home palliative care
Authors: Jaturapatporn Darin , Moran Erica , Obwanga Chris , Husain Amna
Published: March 2012

Background

Dyspnoea is a common and distressing symptom in advanced cancer patients. Our preliminary work shows that in the home palliative care population sampled for this study, the prevalence of dyspnoea is 29.5% and of those, 26.2% used oxygen therapy. Previous studies suggested that oxygen therapy can be a burden to patients.

Purpose

This study seeks to report the prevalence and describe the experience of dyspnoea, pattern of oxygen use, and patients' perceived benefits and/or burdens of oxygen therapy in home palliative care patients receiving oxygen therapy.

Methods

Qualitative indepth interviews, using an interview guide, were conducted with eight participants in their homes. Thematic analysis was performed using a framework approach.

Results

All patients in this project used oxygen most of the time. The descriptions of shortness of breath varied and were non-specific. The patients identified more advantages than disadvantages. The advantages of oxygen use included increased functional capacity, patients' perceiving oxygen as a life-saving intervention, as well as a symptom-management tool. The identified disadvantages were decreased mobility, discomfort related to the nasal prongs, barriers to accessing oxygen therapy and noise related to the equipment.

Conclusion

The advantages of oxygen usage outweighed the disadvantages for this sample of patients in the home palliative setting.
The role of percutaneous cordotomy for management of severe cancer pain
Authors: Hugel Heino , Sharma Manohar , Goebels Andreas , Frank Bernhard
Published: March 2012

Background

Percutaneous cervical cordotomy (PCC) is a nerve-destructive procedure for severe unilateral cancer pain related to mesothelioma and other cancers.

Aims

Prospective case series of patients undergoing percutaneous cordotomy for cancer pain.

Methods

Prospective data collection for consecutive patients who underwent percutaneous cordotomy through a joint pain/palliative care clinic at a large regional pain centre in the Northwest between 2/2008 and 6/2011. Patients were assessed 1 day prior, 2 days post procedure as well as 4 weeks postprocedure. Average and maximum pain scores on a numerical rating scale (NRS) ranging from 0 to 10 of pain 24 h prior and 48 h and 28 days post procedure, the global impression of change scale, morphine equivalent 24 h prior to and percentage reduction after procedure and side effects from procedure were recorded.

Results

39 patients underwent PCS. Most common diagnoses were mesothelioma (19 patients) and bronchial carcinoma (10 patients). 29 patients had chest wall pain. Mean pain max score 24 h prior to procedure was 8.5 (SD 1.7) and 1 (SD 2.1) and 2 (SD 3.1) 48 h and 28 days post. Average pain score was 6.5 (SD 1.8), 0.85 (SD 2.1) and 1.9 (SD 2.98). Morphine equivalent dose median 140 mg prior to procedure and 50% reduction post procedure. Nine patients felt very much better, 23 patients much better on global impression of change scale 2 days post procedure. No patient had irreversible side effects from procedure.

Conclusion

PCS is a highly effective procedure for unilateral refractory cancer pain due to mesothelioma and other cancers in well selected palliative patients.
Therapeutic and postmortem opioids levels
Authors: Siddiq Ibrahim , Noble Bill , Morley Stephen
Published: March 2012

Background

The range of opioid dose in patients receiving palliative care is wide and not directly related to response. The levels of opioids in therapeutic and postmortem, population group studies and forensic studies have been studies in published data.

Aim

To describe the results of studies of opioids levels in living patients receiving palliative care treated for pain, and in postmortem studies between 1970 and 2009.

Method

Literature review of studies concerning five of the opioids; Diamorphine, Morphine, Oxycodone, Fentanyl and Methadone, by using: Hand Search, Cochrane library (systematic Review) and Medline OvidSP, in english language. The level of evidence on each clinical study or review is determined and the evaluation focuses on the relationship between doses and opioids levels, in overdose and therapeutic use.

Results

The authors found few studies in palliative care describing fatal events and blood levels in opioid overdose with variation in level, due to differences in drug metabolism. Overall 300 papers were reviewed, 251 of studies were reviewed in therapeutic and postmortem. Number of papers 71 of Studies of ante-mortem/population Group studies/therapeutics (pharmacokinetics, overdose addiction (maintenance),postoperative,cancer pain, tolerance, respiratory depression,withdrawal and data collection(dose finding)). Number of papers 180 of studies of postmortem/cadaver group studies/plasma levels (Fatal suicides, trauma victim, and accident death, coincidental and other conditions). The remaining 49 of studies were concerned with (mechanisms, switching, drug monitoring and controversy over drugs use).

Conclusions

Measurement of the relationship between fatal events and opioid blood levels is difficult, due to laboratory error, blood contaminants and variations between individual subjects. It does not appear to be wise to infer opioid levels in life from postmortem evidence in cases of therapeutic opioid use.
Quality end of life care
Authors: Johnstone Ros , Fowell Andrew
Published: March 2012

Implemented on an all-Wales basis in 2000 the Welsh Integrated Care Pathway (ICP) for the last days of life has gone from strength to strength. Starting with 38 sites there are now over 100 sites using the ICP to deliver quality end of life care in a variety of settings including: hospitals hospices specialist in-patient units and in the community. Centrally collecting and analysing the ICP variance sheets has permitted quality monitoring and benchmarking exercises facilitating feedback and informing the on-going development of the ICP tool Variance monitoring shows that the incidence of goal variances associated with the management of pain, agitation and excess respiratory secretions or rattle have decreased over time, indicating a higher proportion of goal achievement and improvement in optimum care. The same tool is used for cancer and non-cancer patients with no differences between the two patient groups on length of time on the pathway or frequency of goal related reported variances. The ICP has recently undergone a thorough overhaul and the new pathway has been taken up and used throughout the principality.

Conclusion

It is possible to implement, sustain and maintain the use of the ICP over a wide geographical area and for different patient groups, ensuring that quality end of life care can be delivered in different care settings. Currently there is a strong move to develop and implement an ICP for end of life care in intensive care units, adopting the same model of implementation therefore facilitating a Wales wide implementation monitoring and feedback process.
A programme of care in palliative day care
Authors: Jones Angela , Williams Ann , Johnstone Ros
Published: March 2012

Palliative day care aims to help patients and carers to live a good quality of life within the limitations of their illness. The last 30 years has seen an exponential growth in the provision of palliative day care places throughout the UK. The purpose built day hospice for patients of Gwynedd and Anglesey that opened in 2002 in North West Wales provides nursing care and a range of complementary therapies. The day hospice can host up to 12 patients a day, for 4 days a week. As time passed and the hospice grew more established, a wider range of therapies were available to patients. The result being, that the patients became overwhelmed by the options and the hospice day lacked structure while the calm, relaxed atmosphere was jeopardised. To combat this and facilitate a simpler choice for patients, the team developed a planned programme of care (POC) that was structured yet permitted the patient to make an independent choice of therapies. The outcomes of implementing the POC are that the calm and relaxing atmosphere is preserved, the patients are not overwhelmed and staff feel that they are giving their patients individualised quality care. The POC carries the potential to be transferred to other day care settings and different patient populations.
Supporting healthcare professionals in three clinical settings to engage in advance care planning
Authors: Whigham Jackie , Spiller Juliet , Finucane Anne , Adam Joan
Published: March 2012

The Department of Health's End of Life Strategy (1), Living and Dying Well: Building on Progress(2) and NHS Lothian's Palliative Care Strategy 2010 (3) all recommend a ‘thinking ahead’ philosophy (ACP) for all patients in the palliative phase of an illness and outcomes shared electronically. NHS Scotland recommends using the electronic palliative care summary (ePCS) as an aniticipatory care plan (3). A 1 year collaborative project aimed to identify ways to support implementation of ACP in three clinical settings: hospital, social care home and a GP practice. In each setting the project: used a learning needs analysis to identify learning objectives developed an educational resource delivered ACP education evaluated learning outcomes identified champions in each setting worked collaboratively with the project lead to optimise engagement and learning outcomes. The learning needs analysis identified: limited understanding of ACP an informal unstructured approach to the process perceived barriers to the practice of ACP although the identified learning objectives were the same, the educational approach was adapted for each setting. The learning objectives were: define what is meant by Advance Care Planning Explore who may benefit describe what Advance Care Planning may lead onto be aware of the clinical tools (ePCS etc) used to record and share the outcomes from Advance Care Planning discussions explore role and reflect on the process in setting. This project established successful educational approaches to support the implementation of ACP in three different clinical settings. The champions in each setting have committed to review their current ACP processes and make improvements in collaboration with their teams. Further evaluation will be presented at the conference and will provide valuable information relating to the longer term impact on patient care.
Palliative medicine and smartphones: an opportunity for innovation?
Authors: Nwosu Amara , Curi Stephen Mason Marie
Published: March 2012

Background

The use of smartphones and their applications are providing health professionals with opportunities to integrate technology into clinical practice. The number of work-related applications available to health professionals is increasing. Certain specialities have a large number of resources available for health professionals; however, the availability of applications specific to palliative medicine is, as yet, limited.

Aim

To review all smartphone applications available to the five most popular operating systems (iPhone, Blackberry, Android, Palm and Windows) which are targeted to health professionals within palliative medicine.

Methods

Each smartphone app store was queried with a combination of the following keywords: palliative, pain, cancer, symptoms and medicine. The applications were purchased and tested if their title and/or description showed relevancy to palliative care.

Findings

Six applications specific to palliative medicine were identified across all five operating systems. These consisted of blog orientated applications (Pallimed and Geripal), an app containing guidelines from eight cancer networks (PalliApp), an education based app (Palliative Care) and opioid dose converter applications (eOpioid and PalliCalc).

Conclusion

There is a lack of palliative medicine specific resources available for smartphones. No literature currently exists to examine the potential benefits of mobile technology on learning, clinical practice and professional development. This is an opportunity for further research and development. Academic institutions could partner with technological developers to improve access to, and dissemination of information. Considered development of mobile technology has the potential to improve patient care, data sharing and education within the speciality.
Pain from subcutaneous injections: myth or reality
Authors: Srivastava Leena , Robson Peter
Published: March 2012

Background

The use of the subcutaneous route is well established in Palliative Care. It is the most commonly used parenteral route for administering drugs when the oral route is not suitable. Based on ‘clinical experience’, it is often taught that subcutaneous injections are less painful; however, there is a paucity of evidence.

Aim

The aim of this survey was to evaluate the incidence of pain from subcutaneous injections and explore the factors likely to influence pain.

Method

A prospective survey was carried out at St Benedict's Hospice, Sunderland, UK in 2010 over a 1 month period. Data were collected for 50 consecutive injections, either given singly or via a subcutaneous cannula.

Results

76% of injections were not painful, 18% caused discomfort and 6% caused pain. 100% of injections causing pain were given singly. 45% of injections which were not painful were through subcutaneous cannulas. The insertion of subcutaneous cannulas did not cause pain.

Limitations

Pain from subcutaneous injections is influenced by various concomitant factors and as our sample size was small, it was difficult to evaluate the specific role of individual factors. Moreover, all commonly prescribed drugs in Palliative care were not used. Discussion: This survey shows that most patients do not experience pain from subcutaneous injections. There was also a lower incidence of pain when a subcutaneous cannula was used for injections. There are currently no guidelines on the insertion of such cannulas. From our data, patients who need repeated injections will benefit from them early on.

Conclusion

Our survey has shown that the majority of patients do not experience pain from subcutaneous injections. Further multicentre studies are needed to clarify the role of individual factors which may cause pain.
The management of malignant ascites in Palliative care: An audit of clinical practice and development of standards and guidelines
Authors: Johney Leslie , Chapman Laura , Allsopp Leslie , Curie Marie , Gray Dawn , Griffiths Anne
Published: March 2012

Background

Malignancy is the underlying cause in approximately 10% of all cases of ascites. About 15–50% of patients with malignancy will develop ascites. Cancers commonly associated with the development of ascites include breast, colorectal, endometrial, gastric, ovarian and pancreatic cancer. Several pathophysiological mechanisms are implicated in the development of malignant ascites. Management should be aimed at maximising patient comfort and quality of life. Management options include diuretic therapy, therapeutic paracentesis and peritoneovenous shunts. Oncological interventions maybe helpful for patients with ovarian malignancy and lymphoma. Hormonal treatments maybe useful for management of receptor positive cancers like breast cancer.

Aims

A supra regional re-audit of palliative care network practice was performed which established compliance with regional guidelines. Two questionnaires were developed. The first questionnaire gathered information on individual anonymised patients with ascites. The second questionnaire focused predominantly on clinical practice when carrying out paracentesis.

Methods

A prospective case-note audit of patients with ascites within specialist palliative care services in the network. Data were collected over 6 months from hospice, community, hospital advisory palliative care teams. Collected data included management of ascites with drugs, paracentesis and the use of permanent indwelling catheters for the management.

Results

More than 50% of patients had an Ultrasound prior to drainage of ascites. 30% of patients had paracentesis at the Hospice. Only 40% of staff had access to units where permanent indwelling catheters was being inserted. Most units did not have a scanning device in house.

Conclusion

Examination of current practise in the Merseyside and Cheshire Cancer Network shows that management of ascites is predominantly using diuretics and paracentesis as per previous standards and guidelines. However there are units who now insert permanent indwelling catheters. Some units also have their own ultrasound device for diagnosing ascites and marking out the site of needle insertion.
Audit on documentation of steroid usage in palliative care patients in a UK inpatients' hospice
Authors: Subramaniam Sivakumar , Newens Paula , Vellaturi Krishna , Caio Bettini , Marshall Jane , Fisher Simon
Published: March 2012

Steroids are commonly used medications in palliative care patients. It is well known that inappropriate or prolonged prescribing of steroids could be harmful for patients. An Audit of documentation of steroid usage in in-patients was completed in 2007 at three hospices with 90 patients. This recommended (1) every patient on steroids must have indication, dose, response and planned length of treatment documented. It may be feasible to record this in both case notes and drug chart. (2) All patients on steroids and NSAIDs should be on a PPI. (3) All patients discharged on steroids should have a management plan documented.

Aim

To evaluate our current practice against the recommendations from the 2007 audit.

Methodology

Retrospective, case notes &drug chart review of all the patients discharged from two inpatients' units from November 2010 to May 2011 with 32 beds in total.

Results

Total patients: 133, patients discharged on steroids: 60 (30%). Indication documented: 52/60; Response clearly documented: 37/60.Planned duration documented: 40/60.Patient on steroids and NSAIDs not on PPI: 2/5. No documented plans about steroids in discharge letter: 28/60.

Conclusion

A significant number of patients are discharged on steroids from inpatients' units. However, the documentation of indications, planned length of use, response to the treatment and reduction plans needs further improvement. One of the main findings from the audit is that the documentation regarding steroid prescription and planned reduction in discharge summaries needs to be significantly improved. It is recommended that a separate box be added to the discharge letters regarding steroids and plans of reduction and introduce steroid card for the patients to carry to alert the professionals. To re-audit in 2 years time to check progress.
The clinical and strategic impact of generic documentation for end of life anticipatory prescribing
Authors: Wenham Sarah , Smith Kathryn , Taylor Chris , Atcheson Lynn , Greenall Melanie , Haythornthwaite Cherith
Published: March 2012

Background

The End of Life (EoL) Care Strategy (2008) recommends that consistent ‘co-ordination of care’ and ‘delivery of high quality services in all locations’ is essential across a healthcare economy. Due to historical development and redesign of community services within a large healthcare economy in the north-west of England, we found ourselves with three different community policies for anticipatory medication at the EoL and five different prescription and authorisation forms. Cross-organisational collaborative working is essential to develop consistent standards that provide the high quality of EoL care and minimise potential risk.

Aim

To assess the clinical impact of generic documentation for ‘Just in Case 4 Core Drugs’ (JiC4CD) anticipatory prescribing at the EoL across a healthcare economy.

Method

A multi-disciplinary group of clinical experts from all the key stakeholder organisations within the healthcare economy reviewed the existing processes and documentation, and an ideal clinical pathway was agreed. A Task and Finish group designed and implemented new documentation in line with this pathway, including: • prescribing guidance • single prescription and authorisation booklet • JiC4CD pack (issued from community, hospital and hospice pharmacies) • audit form Audit forms were completed by the primary healthcare team and returned for analysis using simple statistical methodology.

Results

The clinical impact of the JiC4CD booklet and pack was demonstrated with regard to: • EoL symptom control • prescribing and administration clinical incidents • crisis domiciliary visits and unplanned hospital admissions • place of death • carer satisfaction • healthcare professional satisfaction Facilitating factors and barriers to implementation will be discussed.

Conclusion

Single generic documentation for JiC4CD anticipatory medications across a healthcare economy not only has a positive impact on individual patients, but the process also demonstrated benefits of cross-organisational partnership collaboration to achieve ‘high quality care for all adults at the EoL’.
Radiology imaging in the hospice setting
Authors: Beggan Shane , Rayment Clare , Ward Jason
Published: March 2012

Background

There is little literature available regarding the use of radiology services within the hospice setting. St Gemma's Hospice in Leeds has a 32-bed inpatient unit with around 600 admissions per annum and a day unit and outpatient service reviewing 400 patients a year. It accesses the local hospital trust for imaging.

Aims

To collate all radiology requests over a year to determine the frequency of different imaging modalities and what proportion detected the anticipated result or an alternative explanation for symptoms. Secondary aims included the proportion of patients who died within 2 weeks of imaging and examining the cost of imaging.

Method

Data were collected retrospectively from the radiology IT department at Leeds Teaching Hospitals NHS Trust. It included details of all imaging requested for inpatients and outpatients between 1/1/10 and 31/12/10 by Doctors within the hospice.

Results

51 patients had 62 scans: 21 CTs, 18 MRIs, 10 Ultrasound scans, 4 CXRs, 4 AXRs, 3 Nuclear bone scans and 1 barium swallow. The most common reasons for imaging were for possible brain metastases (13), or spinal cord compression (12), 29% and 25% respectively were positive. Imaging for venousthromboembolism (11), and disease progression (6), were the next most common reasons for scanning, 27% and 67% respectively were positive. Scans showed an explanation for symptoms in 5/12 (42%) for SCC, 5/13 (38%) for brain mets, 5/5 (100%) for PE and 5/6 (83%) for disease progression. 11% of patients died within 2 weeks of having their scan. The approximate total cost based on NHS average reference costs was just under £10,000.

Conclusion

Most scans were appropriately requested. Depending on the imaging between 25 and 100% showed some abnormality. Most imaging was avoided in the 2 weeks prior to a patient's death. The costs associated with imaging are significant.
Intravenous cannula care in the inpatient hospice setting
Authors: Newens Paula , Rowlstone Theresa , Butler Claire
Published: March 2012

Background

There is little data on the subject of practical procedures in hospices. The Minimum Data Set, collected annually by the National Council for Palliative Care, recorded clinical interventions for the first time in 2008–2009. Response rates remain too few to draw conclusions. Anecdotally, there has been an increase in practical procedures with growth of the modern hospice movement. Bloodstream infections account for 7% of all healthcare associated infections (HCAI) in England and are associated with high level of patient mortality. Around 44% of these infections are directly attributable to invasive devices. It has been estimated that each HCAI costs the NHS £4,300 totalling at least £1 billion.

Aims

To assess current practice of insertion and ongoing care of intravenous cannulae in the inpatient hospice setting. To develop new strategies to promote best practice guidelines.

Methods

The documentation relating to 10 consecutive intravenous cannula insertions was recorded prospectively at an inpatient specialist palliative care unit. Ward staff were blinded to this to minimise observation bias. Documentation for each cannula was assessed retrospectively against NHS guidelines and standards. New documentation was developed. Following a trial period, the insertion and ongoing care of cannulae were reaudited across the organisation, comprising three inpatient specialist palliative care units. Twenty consecutive cannulae were recorded and assessed retrospectively.

Results

The initial audit showed an average of 14.7% compliance with the national guidance which increased to 68.6% after the introduction of the new documentation. The Mann–Whitney test suggested a statistically significant (p=0.0006) improvement in recording of cannula care.

Conclusion

It is important that evidence-based guidance is used across all areas of healthcare to improve patient care. Introduction of a quick, simple, self-contained recording system can produce a significant increase in the evidence of good cannula care.
Ambulatory epidurals: an innovative alternative
Authors: Thompson Anthony , Coackley Alison , Levshankov Kosta , Haywood Chris , Barton Greg , McConaghy Margaret
Published: March 2012

Background

Continuous epidural infusions are often delivered by pumps that require changing every 24 h. This limits patient independence and quality of life and provision in the community can be difficult. Alternatives can be extremely expensive with limited availability for example, implantable devices.

Methods

The Accufuser Elastomeric Vacuum Pump device delivers a near linear infusion with a patented piston over 5.7 days. The infusion can be prepared aseptically in the Pharmacy department.

Discussion/Results

This report describes the challenges and benefits of implementing a new approach to delivering epidural infusions in four patients. The device has been tolerated well, and used on four separate occasions. Longest duration of use was 14 weeks and is on-going. Robust device which is lightweight, easy to manage and does not depend on batteries. Good evaluation from patients. Easy, flexible drug titration. Combination of drugs can be varied according to compatibility studies. Change of device is managed easily by staff following appropriate training. The device is cost effective and allows patients to maintain mobility and independence. It has been accepted by community staff. This device has no significant safety issues or complications.
Use of intravenous bolus doses of ketamine for acute refractory pain
Authors: Ahamed Ashique , Spawton Vanessa , Wells Lynne , Newell Elizabeth , Ahmedzai S H
Published: March 2012

Background

Ketamine is used in palliative care to help relieve refractory pain that does not respond to conventional opioids or adjuvant analgesics. It is commonly administered via subcutaneous or the oral route. This however has its limitations since ketamine infusion can cause skin irritation and result in its reduced absorption and intolerable adverse effects We demonstrate our experience in the use of intravenous (IV) bolus doses of ketamine to help control acute pain as well as to help assess adverse effects which can predict the appropriateness of commencing a subsequent infusion of ketamine.

Aim

Prospective review of patients receiving IV bolus ketamine in a tertiary cancer hospital from August 2010 to September 2011.

Method

Administration of Slow IV bolus doses of ketamine. Titration of ketamine depending on improvement in pain relief or advent of intolerable adverse effects. Assessment of extent of pain relief following administration of ketamine. Patients were asked to rate pain from 0 (no pain) to 10 (worst pain) The pain scores were taken prior to and during and post administration of ketamine.

Results

Eleven patients received IVbolus doses of Ketamine during this period.All patients received haloperidol 1.5 mg s/c prior to IV ketamine. The average age of patients 47 Mean pain score prior to initiation of ketamine 8/10 Background opioids in morphine equivalent doses (MEQ)ï¿½Mean MEQ=330 mg average dose of ketamine administered=20 mg(range7.4–40 mg). Average pain score post administration=2/10 adverse effects: drowsiness 63%, intoxicated feeling 18% severe visual hallucination 9%. One patient required administration of IV midazolam to counter the adverse effects. Nine out of 11 patients conitnued with either s/c or IV infusions of ketamine.

Conclusion

Administration of IV ketamine is an effective and safe method in managing acute pain in palliative care
End of life care in the district general: are we making the most of every opportunity?
Authors: Procter Lucy , Lightfoot Jennifer , Wilson Jo , Lisney Fiona , Russell Richard
Published: March 2012

Background

Heatherwood and Wexham Park NHS Foundation Trust manages 1200 deaths per year. Of these, an unknown percentage is expected, and appropriate for the Liverpool Care Pathway (LCP), a national tool designed to optimise care in the terminal phase. In a busy District General Hospital, our challenge is to accurately select dying patients for management on the LCP.

Aims

On an acute medicine and respiratory ward, we aimed to establish: The quality of care provided for dying patients. The percentage of deaths managed on the LCP. The number and reasons for missed LCP opportunities. Method: All deaths on an acute medicine and respiratory ward during November and December 2009 were retrospectively analysed by an interdisciplinary panel using a locally developed data collection tool.

Results

For 22 deaths, 20 case notes were available. Cause of death was divided into three categories: acute illness (36%), long-term condition (41%) and malignancy (23%). For all deaths, inappropriate medications were discontinued, feeding and hydration issues were addressed, and DNACPR documentation completed. 32% of deaths were managed on the LCP. Anticipatory comfort prescribing (86%), documented communication with relatives (86%), and evidence of patient comfort (71%) were superior in this group. LCP was inappropriate in the remainder because of active treatment (69%), unanticipated cardiorespiratory arrest (23%) and patient refusal to accept terminal diagnosis (8%). The panel concluded that two of these could have been managed on the LCP.

Conclusion

On an acute respiratory/medical ward, 40% of deaths were appropriate for the LCP. Only two LCP opportunities were missed. Evidence of patient comfort and communication with relatives was superior for patients managed on the LCP. For gravely ill patients deteriorating despite active management, the implementation of ceilings of treatment and parallel palliative interventions such as anticipatory comfort prescribing may enhance care.
Do patients referred to specialist palliative care (SPC) die where they prefer? A network-wide audit
Authors: Scholes Carol , Allan Rebecca
Published: March 2012

Background

‘There is currently a significant gap between preferred and actual place of death, with over half not dying where they would choose, too many dying in hospital and too few in their own home, care home or hospice’ Gold Standards Framework.

Aim

To perform a network-wide audit of the Preferred Place of Death (PPD) of patients known to SPC to ascertain whether their wishes were fulfilled. Method: Data was collected from SPC clinicians regarding last expressed PPD, actual place of death, and reasons for discrepancy for all patients known to SPC teams (communities, hospices, hospitals) across the Mount Vernon Cancer Network. The study period was 3 months.

Outcomes

708 consecutive patients were included – 320 (45%) died in hospital, 179 (25%) at home, 172 (25%) in hospice, 28 (4%) in care home and 9 (1%) unknown. (a) Outcomes where PPD known: 426 (60%) had a PPD which were 184 (43%) home, 159 (37%) hospice, 53 (13%) hospital, 30 (7%) care home. 349 (82%) achieved their wishes. 77 (18%) died elsewhere due to unexpected deterioration (34), physical condition (14), continuing healthcare delays (13), lack of family agreement (6), no available bed (3), unknown (7). A patient was 5.5 times more likely to die at home. (b) Outcomes where PPD unknown: 282(40%) had unknown PPD. 215(76%) died in hospital, 35(12%) hospice, 18(6%) home, 10(4%) care home, 4(1%) unknown. A patient was 3 times more likely to die in hospital.

Conclusion

82% of patients with known PPD achieved their wishes. Physical symptoms and unexpected deterioration were the primary reasons cited for those dying elsewhere. 40% of patients had no known PPD and of these 76% died in hospital. Extension of discussion and documentation of PPD to more patients would increase patient choice and is likely to reduce numbers of patients dying in hospital, and increase deaths at home across this population.
How to provide consultant peer support – the south coast new consultants group
Authors: Ford-Dunn Suzanne , Barclay David
Published: March 2012

Introduction

Peer support is identified though the NHS appraisal process and national bodies such as Royal Colleges, as being essential for the on-going wellbeing and professional development of consultants. It is recognised that the early years as a consultant can be particularly stressful and that palliative medicine consultants have difficulty obtaining peer support since many work in isolation. We identified a lack of peer support within our area.

Description

A new consultants group was formed in 2009, using loose geographical boundaries of the Sussex Cancer Network – involving 10 ‘new or soon to be’ consultants. The group meets 4 times per year, topics relevant to new consultants are agreed and organising each meeting is shared. Meetings either have invited external speakers or are run by one of the members. The meetings aim to provide CPD (topics include Commissioning, managing CNS's in difficulty, writing a business case etc) but also to provide members with time to discuss any issues that have arisen, clinical or non-clinical. The group is cost effective in that SPA time is used for the meeting, with costs for speakers/meeting rooms etc covered by sponsorship if needed.

Benefits

Consultants in isolated posts have found the peer support invaluable. Feedback from members is highly positive – further evaluation is underway to produce data to support its effectiveness. The presence of our group has been used by local units to enhance the attractiveness of new consultant posts. Future plans: As some members reach the end of their first 5 years in post, and Consultant vacancies in the area are filled, debate is occurring as to the terms of reference of the group. The support has been so effective it is proposed to continue meeting, but extending membership to become a generic doctors' professional development meeting.
Innovation in a nurse led community unit: expanding the role of volunteers
Authors: Kirkland Gill , McKenna Emer
Published: March 2012

In response to National guidelines and local need to offer an alternative place for end of life care when patients no longer wish to die at home, we built three independent living units from a government grant. The authors now offer our population of approx 500 000 the opportunity for nurse-led respite and end of life care, in a homely environment. We deliver 24 h care from a dedicated team of healthcare support workers and specially trained volunteers, supported from our community specialist palliative care nurse team who are independent prescribers. The aim was to provide high quality, low cost care for patients and their family. Utilising our team of volunteers, we selected 26 volunteers to undertake extended education and training who were able to demonstrate competency in caring for palliative patients and their family. The training includes end of life care and palliative care, basic communication skills, role of multi disciplinary team, manual handling and infection control. In fact 14 have enrolled to undertake their NVQ at diploma level and we are currently exploring specialised bereavement training with memory boxes. The authors acknowledge that we may experience a rapid turnover of voluntary staff that could move into permanent employment; however this framework of offering training and utilising their skills is cost effective, highly skilled and up-to date. This training has been possible by linking with a local college and using the expert skills of one of our HCSW who is a NVQ assessor. Through the dedication of the voluntary staff and trainers we have been able to provide excellent cost effective patient care during end of life and respite support for families. The feedback from patients and families has been very positive.
An audit of rehabilitation input for patients with brain and spinal tumour within the Greater MancheSTER
Authors: Robson Sara , Emerson Julie , Connor Neil
Published: March 2012

Background

In 2008, the National Cancer Action team started a cancer rehabilitation workforce scoping exercise. As a result of this, eight cancer disease group rehabilitation pathways and four symptom specific pathways were published in 2010. The pathways were written following all available evidence and examples of best practice, where evidence was not available. (National Cancer Action Team; Briefing Paper 2 CRWP September 2008) As part of our role we were given the task of introducing the Brain and CNS rehab pathway to our local cancer network (Greater Manchester and Cheshire Cancer Network). We were required to localise the pathway and examine how closely the rehab provided for the brain and CNS tumour patients was following the suggested ‘best practice’ in the rehab pathway. We had assistance of the local Supra District Audit office to audit the existing pathway and rehabilitation interventions prior to our input, and re audit following a year of education and promotion of the pathway.

Aim of the presentation

The aim of the poster is to detail the processes that led to the production of a successful audit tool, and to discuss the ‘trials and tribulations’ of carrying out a regional audit of patient notes which spanned numerous separate agencies. We aim to make others aware of some of the pitfalls surrounding multi agency audit.

Methodology

A retrospective audit of medical/allied health professional notes was carried out on a sample of randomly selected patients diagnosed with a primary brain or spinal tumour within a specified period. All agencies involved have been made aware of the audit and each individual Information Governance Team has had to give approval. As the audit did not involve discussion with patients, ethical approval was not required.
Implementing the LCP ICU Version 12 across a regional critical care network
Authors: Parsons Dawn , Gambles Maureen , Chapman Laura
Published: March 2012

A pilot project is currently underway within the 11 intensive care units within the Mersey an Cheshire Critical Care Network (MCCCN) to implement the recently developed Liverpool Care Pathway for the Dying Patient in Intensive Care Version 12 (LCP ICU). Funded by the Merseyside and Cheshire Cancer Network, this project will provide a mechanism to support units to robustly implement and sustain the LCP ICU Version 12.

Aim

To implement LCP ICU Version 12 into 11 sites with the MCCCN to ensure that: •Appropriate processes and policies are in place to support care in the last hours or days of life •Staff are appropriately educated and trained to deliver that care •A mechanism for the on-going collection/sharing of data (to promote and sustain the delivery of quality care into the future) is developed The Project involves the identification of Key Champions within each participating site who will take responsibility locally for the implementation process. They will be supported by the Project LCP ICU Facilitator to deliver robust education and training to staff and to facilitate and monitor the implementation process. Key Champions will meet monthly with the LCP ICU Facilitator to discuss progress and to share challenges and opportunities. Contextual organisational information from each unit will be collected prior to and post implementation. Alongside this, data from LCP ICUs completed within each site during the project will be collated and analysed descriptively to provide a comparative benchmark of care delivery across the network. Key Champions and the LCP ICU Facilitator will keep reflective diaries throughout the process, which will be analysed thematically to derive an understanding of the process of implementation, including facilitating factors, barriers and challenges. Findings from all facets of data collection will be presented, discussing the implications for wider implementation of the LCP ICU Version 12.
Implementing the GP palliative care register ‘how to’ pack
Authors: Rushbrooke Sarah , Kendrick Elizabeth
Published: March 2012

Background

The palliative care registers were introduced as a quality and outcome framework measure to try to improve the care of people at the end of their life. Research and local experience tells us that the registers are used in very different ways within and between GP practices. Carers frequently tell us about poor coordination of care for people at the end of their life and one of the outcomes within the new NHS outcomes framework to be measured is carers' satisfaction with their loved ones end of life care.

Aims

The purpose of this guide is to support GP's to make the palliative care register work for their patients and improve their outcomes in palliative and end of life care. The SHA End of Life Clinical Innovation Team (CIT) and the North of England Cancer Network (NECN) have worked with a number of dedicated clinicians and IT experts to develop the ‘How to Guide’ to support GP's to use their registers effectively. A Rapid Improvement Workshop (RPIW) was held, which is a service improvement method, to look at the process of the palliative care register and gathered data from other parts of the UK to write the guide. In addition, the agreed GP Palliative Care pack will be shared with the national QIPP and End of Life team with the explicit aim of working with the Care Quality Commission (CQC) to adopt the process as part of the inspection of GP practices. The pack will be implemented across the SHA and network from October 2010 to all GP practices and an audit of compliance will be completed.

Outcomes

It is envisaged that all GP practices will adopt the ‘How to’ Pack and the project team will work with the individual practices to ensure it is embedded in every day practice.
Impact of a local enhanced service agreement for end of life care on collation of a palliative care
Authors: Westwood Debbie , Baghsaw Kerry , Curtis Claire , Hospice Kemp , Blaine Kidderminster Felix
Published: March 2012

Background

The Local Enhanced Service agreement (LES) for End Of Life (EOL) care was started by Worcestershire Primary Care Trust in 2009, and is now in its 3rd year, with the aim of developing good practice and improving EOL care in Worcestershire. GPs have been asked to sign up to and fully adopt the Gold Standards Framework (GSF), including collating a palliative care register, use anticipatory prescribing, use the Liverpool Care Pathway for all dying patients, apply the GSF surprise question to all care home residents. All GPs in participating practices were expected to complete 2 h-long learning modules, and each practice had to nominate a lead GP to attend a 1 day study day each year.

Outcomes

IT software from MSDi installed on all GP surgeries to collect data. Practices were offered 50 pence per patient on the practice list. 60 out of 68 GP practices signed up for the first 2 years, and 339 GPs completed education modules. The number of people on the palliative care register increased from 500 in 2006/7 to 1983 in 2010/11. The proportion of deaths in acute hospital has reduced from 45.4% in 2007/8 to 42.0% in 2010/11. 27% of patients on the palliative care register who died at home or in a community hospital were placed on the LCP.

Conclusion

Already data shows that a patient on a palliative care register is more likely to die at home than someone not on such a register, and we have achieved a 3.4% reduction in the proportion of deaths happening in the acute trust since 2007/08, which equates to a 5% reduction in the numbers of people dying in the acute.
Clinical innovation through leadership development
Authors: Coackley Alison , Bonwick Helen , Chapman Laura , Wrigley Kim , Powell Paula , Mayland Catriona
Published: March 2012

Background

Senior clinicians and managers are at the forefront of innovation within Palliative Care. This places significant demands on professionals who need specific skills to maximise their effectiveness and their impact in the clinical workplace. Merseyside and Cheshire Cancer Network funded a Leadership Impact Programme for Consultants in Palliative Medicine. This links leadership style directly with engagement, wellbeing and performance which in turn helps individuals to encourage change and innovation in their organisation.

Method

Diagnostic management tools, participation in a coaching centre with feedback, development workshops, and peer support. Subsequent Action Learning Sets over 12 months then facilitated participants to use their skills to produce change and innovation in their workplace.

Discussion/Conclusion

The course was designed to meet the needs of the individuals and the group in general. Participants included seven senior clinicians and two senior clinical managers Evaluations were extremely positive with many specific examples of how learning and experiences from the course had impacted on clinical services across a range of organisations. 100% of participants felt the programme had met their personal objectives either very well or completely. All reported a marked improvement in strategic awareness and ability to influence. Results included enhanced team development and leadership leading to integration and improved communication; ability to deliver significant change in an organisation; sharing of new ways of tackling challenges and the commitment to collaborative ventures which were both cost effective and innovative The success of the programme has encouraged the Network to support a second 12 month course for a further cohort of senior clinicians.
Audit of LCP anticipatory medicine prescribing at a large teaching hospital
Authors: Dyer Jen , Dickman Andrew
Published: March 2012

Introduction

The (LCP) is a programme within the Marie Curie Palliative Care Institute Liverpool (MCPCIL) portfolio and should be undertaken and managed by a multi-disciplinary team. It is an integral part of the End of Life Care Strategy. The aim of the LCP is to ensure that all dying patients, and their relatives and carers, receive a high standard of care in the last hours and days of life. The LCP template can be adjusted to enable the creation of local guidelines for use within a clinical setting. The LCP incorporates treatment algorithms for five of the most common symptoms experienced by the dying patient that is, pain, agitation, respiratory tract secretions, nausea/vomiting and dyspnoea. The algorithms stipulate that anticipatory medicines should be prescribed pro re nata (PRN) in case these symptoms develop and to avoid unnecessary delay in their treatment.

Aim and Objective

To assess the current level of LCP anticipatory medicine prescribing compared to local Trust guidelines and identify any potential training needs.

Method

This retrospective audit was performed over a period of 1 month, with a total of 32 patient records being identified.

Results

Only 37.5% (12/32) inpatient charts adhered to the Trust's LCP guidelines. The remainder contained one or more prescribing errors (n=53 identified). The most common error identified (68%) was omission of one or more of the anticipatory medicines. Confusion as to which opioid to prescribe was also evident; diamorphine is presently the first-line choice.

Discussion and Conclusion

This audit showed that 62.5% of LCP anticipatory medicine prescribing was non-compliant with Trust guidelines. Additional training needs have been identified and a programme of education and training can be developed. Once this has been established, the inpatient charts should then be re-audited to check for improvement and compliance.