bluuebunny/crossref_metadata_2025 huggingface dataset:
THINK DELIRIUM! AN AUDIT OF ASSESSMENT OF COGNITION DURING ADMISSION TO A SCOTTISH PALLIATIVE CARE UNIT
Authors: Pinnell Kathryn
Published: February 2014

Background

Delirium is prevalent in the palliative care patient group. It is associated with high morbidity and mortality rates and causes distress for patients and carers. Delirium may be reversible. Assessment and management of delirium are a priority of Healthcare Improvement Scotland.

Method

A retrospective casenote review of 100 consecutive admissions to a Scottish specialist palliative care unit (SPCU) was undertaken.

Aims

The audit aimed to establish whether we assess and document cognition on admission, or within 48 hours, to a SPCU. If there was a documented indicator of cognitive impairment and/or delirium, the audit reviewed whether delirium was screened for and if causes of delirium are considered and treated appropriately.

Results

Seven of 100 patients admitted had a cognitive assessment performed on admission or within 48 hours. In three cognitive assessment was documented as inappropriate or unable to be done. 34 patients had a documented indicator of cognitive impairment and/or delirium on admission. 14.7% (n=5) had a cognitive assessment on admission or within the first 48 hours. None had a documented screen for delirium however 3% (n=1) had a diagnosis of delirium. 9% (n=3) had a diagnosis explaining static cognitive impairment so weren't included in further analysis. 68 % (n= 21) of the 31 patients had the clinically most obvious cause at time of admission addressed, most commonly infection or opioid toxicity, 16% (n=5) had no possible cause documented or addressed and in 16% (n=5) 3–5 possible causes were considered. None had a full assessment of all possible causes of delirium.

Conclusion

Assessment of cognition and delirium screens are not done routinely on admission to our SPCU. There is scope to improve this with further education. In addition a tool will be developed and implemented to aid screening for delirium and assessment of possible causes. Re-audit is planned after implementation.
A scoping exercise to explore the current perceptions and attitudes of UK paramedics towards their role in the management of End of Life Care patients, in the pre-hospital setting
Authors: Kirk Andrew , Crompton Phil , Jack Barbara , Knighting Katherine , Kirt Jennifer
Published: February 2014

Background

Studies have highlighted that clinicians may not feel prepared to deal with end of life care patients as historically their training has been focussed on acute medical and trauma management. This has been shown to cause conflict with paramedic perceptions of their role. Although research exists that explores the attitudes and experiences of health and social care professionals who deal with palliative care patients on a routine basis, there is little evidence that explores the attitudes and perceptions of end of life care within the emergency pre-hospital setting.

Aim of the study

To gain an understanding of UK paramedics perceptions and attitudes towards dealing with End of Life Care patients and carers/relatives.

Methods

An online survey was distributed to all paramedics in the North West of England. The survey contained open and closed questions to enable collection of both qualitative and quantitative data to address the aims of the study. Demographic data including NHS band, personal experience and education & training was gathered in order to contextualise the data.

Results

NHS band and educational background are the main influences on the participants views of End of Life provision provided by paramedics. Length of service as a paramedic and experience appear to be factors that affect confidence when dealing with these incidents in practice. The majority of participants rated that communication about End of Life Care between services is poor. Most participants would like EOL training to be mandatory and would prefer face to face training to self-directed learning packages.

Conclusions

Communication between services is viewed as poor whilst staff backgrounds influences their views. Whilst the majority of paramedics feel that End of Life Care it is a key part of their role, there is a need for wider training to address differences in staff awareness, knowledge and confidence.
A REGIONAL RE-AUDIT OF THE SYMPTOMATIC MANAGEMENT OF NAUSEA & VOMITING IN THE MEDICAL MANAGEMENT OF MALIGNANT BOWEL OBSTRUCTION
Authors: Jackson Timothy , Waterman David , Ahamed Ashique , Lennon Rebecca , Suman Julie , Murray Yvonne , Brady Denise , Harrison Sophie
Published: February 2014

Background

The medical management of symptoms associated with malignant bowel obstruction remains a clinical challenge in palliative care. Where surgical intervention is not appropriate, thorough clinical assessment should guide treatments for nausea and vomiting. In 2011, the North West Palliative Care Regional Audit Group (NWAG) coordinated a multi-centre review revealing variations in prescribing practice and adherence to guidelines. In response, participating organisations were asked to develop action plans.

Aim

To re-audit the assessment and medical management of nausea and vomiting in malignant bowel obstruction against updated evidence-based standards, and compare results with the 2011 NWAG audit.

Method

A regional, multi-centre, retrospective case note audit was undertaken for patients with malignant bowel obstruction. 8 audit standards were produced following an updated literature review. Data was submitted electronically and analysed centrally by NWAG for participating organisations.

Results

Thirteen organisations returned 101 data collection forms (6 hospices, 7 hospitals), an identical number to the original audit. Presence or absence of nausea, vomiting and colic was documented at initial assessment in 77%, 94% 68% respectively (n=101) compared with 80%, 91%, 80% in the original audit. Antiemetics were prescribed via non-oral routes in patients with nausea and/or vomiting in 87% (originally 97%). Where nausea and/or vomiting occurred due to bowel obstruction, regular or continuous non-oral medications were subsequently prescribed within 48hrs in 64% of cases (originally 68%). During an initial 4 day assessment period, if patients required two or more PRN medications for nausea and vomiting in 24 hours, medications were reviewed in 91%. Metoclopramide, if prescribed, was discontinued if colic occurred in 67% of cases. Metoclopramide and cyclizine were prescribed concurrently in 9%.

Conclusion

Whilst this re-audit demonstrates some variation from the original audit, practice was consistent in many areas. Findings support the need for regular and comprehensive clinical assessment in order to maintain effective symptom control.
KETAMINE USE IN PALLIATIVE CARE WITHIN THE NORTH TRENT CANCER NETWORK (NTCN)
Authors: Fingas Samuel , Ahamed Ashique , Ahmedzai Sam H
Published: February 2014

Background

Ketamine is a potent analgesic with potentially serious adverse effects (eg dysphoria, bladder dysfunction), being used in palliative medicine. Its evidence base is limited and a recent RCT using the SC route in cancer pain failed to show efficacy. Neither route nor dosing are standardised, which raises questions for clinical governance in palliative care services.

Aims

To characterise ketamine use in palliative medicine within NTCN, with specific reference to variations in route and dosing.

Method

A short online questionnaire was developed using SurveyMonkey, to capture NTCN palliative medicine consultants' current practices, preferences and opinions. Reminders were used to ensure compliance.

Results

Response rate 15/15 (100%). All had prescribed ketamine in their current post: 100% via SC route, 93% oral, 27% IV. Preference for different routes of administration varied. Ketamine is initiated in outpatient clinics/ day units, and in patients' homes. IV ketamine is only prescribed in hospital/hospice. 86% of consultants discharge patients on ketamine into the community. An estimated 255 patients received ketamine in the previous 12 months. Concomitant opioid reduction varied greatly between physicians. 12/15 physicians switch ketamine routes from SC to PO during treatment. PO and SC ketamine are being used indefinitely. IV treatment is only used as ‘burst’ treatment. 87% give PRN ketamine. Test dose administration varies greatly (53% SC and 100% IV). 5/15 wanted training on IV ketamine. Barriers to ketamine use include cost, community support, and lack of IV pumps. 93% do not use a standardised recording tool. Most organisations do not have a written protocol.

Conclusion

There is significant variation in practice of ketamine use. Despite recent adverse evidence, SC ketamine is most commonly prescribed. Many patients are treated indefinitely and are at risk of side effects. Further studies are needed to establish national usage and to identify priorities for research.
DRUGS AT THE END OF LIFE: AN APPROPRIATE CONCERN?
Authors: Pickard Jonathan , Smailes Rosanna , McKenna Maria
Published: February 2014

Background

The Independent Review of the Liverpool Care Pathway (LCP) described concerns about use of opioid and sedative drugs at the end of life. Baroness Neuberger reiterated the importance of appropriate use of medications to achieve a peaceful death. One concern was that a continuous subcutaneous infusion (CSCI) was started when dying was diagnosed or the LCP commenced, regardless of symptoms.

Aim

To investigate the use of medications at the end of life.

Method

A retrospective audit of deaths within one hospital was undertaken in July 2013.

Results

Of 44 hospital deaths over a one-month period, 82% (n=36) were deemed expected. 56% (20/36 patients) were prescribed anticipatory medications for symptoms of pain, agitation, nausea, vomiting and secretions by the appropriate route and frequency. 100% of anticipatory PRN prescriptions were correctly dosed and 83% were appropriately prescribed parenterally.

72% of patients utilised anticipatory as required (PRN) medication. A CSCI was used in 42% (15/36) of cases. They most commonly contained an opioid to manage pain (93%) and/or a benzodiazepine for agitation (73%), but also included anti-emetic (20%) and anti-secretory drugs (13%). The rationale for CSCI commencement was clearly apparent in 7/15 cases; most commonly it was due to frequent use of PRN drugs (n=6) or as a switch from a regular oral opioid (n=1). A CSCI was used for a mean of 3.9 days.

One limitation of these findings is the reliance on written documentation within the patients' medical notes.

Conclusion and Recommendations

This audit demonstrated that the majority of patients do not receive medication via a CSCI at the end of life, but that most are administered PRN medication for their comfort. The rationale for starting a CSCI should be clearly documented, specifically recording indication for use and communication with patient, family and carers.
PREDICTING WHEN THE LCP MIGHT NOT BE USED?: AN AUDIT OF COMMUNICATION WITH SECONDARY, CONTENT ANALYSIS OF LANGUAGE
Authors: Arolker Milind , Ford Margaret , Marshall Susan
Published: February 2014

Background

Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) provides acute care services and comprises around 1200 beds. Although it participates in the National Care of the Dying Audit (NCDAH), this recurring process previously examined documentation just within the Liverpool Care Pathway (LCP) document. Following adverse media interest in the LCP, we carried out a retrospective casenote audit of deaths examining all documentation surrounding the death of the patients; data was collected from medical, nursing and, if used, LCP documentation regarding communication for patients and relatives about dying in general. When differences in the documented language emerged between notes of patients whose deaths were, and patients whose deaths were not supported by LCP-use, we carried out a secondary, content analysis of random subsets of each of these two groups of notes.

Aims

To assess whether relatives were informed that the patient is dying and to compare differences in documentation language when the LCP was and was not used.

Results

Of 96 adult deaths during October 2012, 83 case notes were available for analysis. After excluding 27 (33%) sudden or unexpected deaths, the remaining 56 (67%) expected deaths split into two sets: 41 (73%) supported by LCP, and 15 (27%) not supported. In both sets, the relatives had been informed that the patient was dying: LCP, 100%; and non-LCP, 93%. However, content analysis revealed that hedged language (terms such as ‘unlikely to survive’, ‘looks to be dying’, ‘un-survivable’) was more frequently documented in deaths unsupported by the LCP, compared to those supported by the LCP, where terms used in the medical notes connoted a greater degree of certainty, e.g. ‘is dying’, ‘not responding to treatment.’

Conclusion

BTHFT' staff document communication about dying well, despite contrary, adverse media reporting. Content analysis results suggest that hedged documentation language is associated with lower likelihood of integrated care pathway use for dying patients.
SIMPLE SKILLS SECRETS: A VISUAL MODEL OF CORE COMMUNICATION SKILLS FOR GENERIC STAFF
Authors: Groves Karen , Jack Barbara , Baldry Cath , O'Brien Mary , Marley Kate , Whelan Alison , Kirton Jenny
Published: February 2014

Background

Every healthcare worker, of any grade or role, can be faced with situations they find difficult to handle, particularly in end of life situations. Rolling out communication skills training to large numbers of people is a challenge. The ‘Simple Skills Secrets’ model was developed to provide an easily remembered visual model for any staff member, in any setting or situation where faced with unanswerable questions or lost for words. The model distils the essence of safely responding to cues, listening, encouraging, summarizing and assisting the formulation of the patient's own plan whilst resisting the urge to rush in with solutions.

Aims

To assess the impact of a ‘Simple Skills Secrets’ model of communication skills training on staff confidence and willingness.

Method

A mixed methods evaluation of impact on staff who had undertaken training included pre and post course assessment of confidence and willingness for 149, and qualitative interviews of fourteen, 6–8 weeks post course, using a purposive sampling approach.

Results

Statistically significant improvement in both willingness and confidence for all categories and staff of all grades. (Overall confidence score, t(148)=–15.607, p=<0.05; overall willingness score t(148)=–10.878, p=<0.05). Greatest confidence change was in communicating with carers (pre course mean 6.171; post course mean 8.171). The value of the model in clinical practice was reported and several themes emerged from the qualitative data including: a method of communicating differently, a structured approach, an easy to remember visual model, thinking differently, increased confidence, using small amounts of time effectively, gaining additional skills and helping the person come up with answers themselves.

Conclusions

This model appears to be easily remembered, increase staff confidence and willingness to engage which may result in earlier, shorter, interventions, minimizing distress, improving patient and carer satisfaction.
SOCIAL MEDIA AND PALLIATIVE MEDICINE: A TWO YEAR ANALYSIS OF GLOBAL TWITTER DATA
Authors: Nwosu Amara , Debattista Maria , Rooney Claire , Mason Stephen
Published: February 2014

Background

Social media involves the use of technological applications to facilitate the exchange of information in a virtual environment. Social media use is increasing in both professional and social contexts. Twitter© is an online social networking service and micro-blogging service that enables its users to send and read text-based messages of up to 140 characters, known as ‘tweets’. Twitter© users can prefix a keyword with a hashtag (#) allowing users to ‘tag’ the message to a particular subject of interest. Social media is used by some palliative care organisations to raise awareness and provide information. However, the degree and scope of the current use of social media to discuss palliative care issues has not previously been reported.

Aims

To determine the frequency, sentiment and trend of ‘tweets’ containing palliative care related hashtags and/or phrases.

Methods

A retrospective analysis of Twitter© of all tweets sent on Twitter© between August 2011 and August 2013, using a social media web analytics tool:TopsyPro©.

Findings

A total of 683.5K tweets containing a combination of 13 palliative care terms were sent on Twitter. The tweet volume has increased by 62.3% annually (262.5K in 2012 versus 421K in 2013). The most popular terms include end-of-life (210K), #hpm (114K) and ‘palliative care’ (93.8K). Sentiment was high with 89% of tweets terms more positive than all other tweets sent in this period. The term ‘Liverpool Care Pathway’ experienced the highest percentage increase in tweets (55% increase) reaching a peak in July 2013.

Conclusions

A lot of discussion about palliative care is currently taking place on Twitter©, and the majority of this dialogue is positive. Social media presents an opportunity engage with the public and professional groups; further work is needed to determine how this can be effectively coordinated.
WHAT TRAINING DO I GET ON THE LIVERPOOL CARE PATHWAY?
Authors: Srivastava Leena , Ting Ruth ,   Members of LCP working group
Published: February 2014

Background

In July 2013 an Independent Review of the Liverpool Care Pathway (LCP) recommended that it should be phased out and replaced by an individual end of life care plan. The review emphasised the need for robust education for clinicians involved in caring for dying patients. It is therefore crucial we understand how staff review the education they receive on the LCP.

Aim

To evaluate clinical staff's views on education they receive on the LCP.

Method

Two wards in Gateshead Health NHS Foundation Trust were randomly chosen. In June 2013, all their staff were invited to complete an anonymous survey. Currently, end of life training is not mandatory and staff access education as per their needs.

Results

Current training

47% of clinical staff responded. 31% were confident they had received training on using the LCP. 46% of respondents felt they were confident in using the LCP.

Future Training

51% of respondents felt that the LCP should be part of mandatory training. 63% would access further training if available.

Limitations

Our results are based on less than 50% response to the survey and may therefore not represent the full views of all staff.

Discussion

Our survey shows that the majority of staff are not confident in the use of the LCP. This may reflect lack of training but also lack of clarity around what education staff may need for caring for dying patients.

In contrast, clinical staff are clearly keen to improve their knowledge and feel a need for mandatory end of life training.

Conclusion

This survey has shown that clinicians perceive a lack of education around the use of the LCP. This will need to be addressed in order to build a confident and competent end of life care workforce.
‘DINING WITH DEATH’ – CONVERSATION MENUS AS A MEANS OF EDUCATING PEOPLE ABOUT DEATH, DYING AND BEREAVEMENT
Authors: Patterson Rebecca , Hazelwood Mark
Published: February 2014

There is growing consensus that palliative care encompasses a ‘health promoting’ element concerned with encouraging openness about death in society so that people are aware of ways to live and support each other with death, dying and bereavement. A general societal reluctance to engage with these issues makes it harder for clinicians to initiate timely discussions with patients about their end of life care wishes.

However, finding ways to educate wider society in issues relating to death and dying can be problematic in a culture where raising these issues is variously perceived as too morbid, too difficult or too sensitive to mention.

This poster describes theDining with Deathmenu and some of the settings in which it has been used, exploring its potential as an experiential learning tool to enable people to become more open about discussing death and dying.

TheDining with Deathconversation menu is a folded piece of A4 card, printed with three ‘courses’ of suggested conversation topics, for example ‘Cremation or burial?’; and ‘What would be in your death plan?’.

The menu was first used November 2011, with 60 individuals from various organisations, who had been invited to a restaurant lunch to mark the launch ofGood Life, Good Death, Good Grief.Since then,Dining with Deathhas been used to facilitate discussions at education events for health professionals and two ‘death cafes’ atJust Festival.

These events indicate the menu has potential as a learning tool: it can be used flexibly, across different types of events and different audiences; it overcomes barriers to engagement in death discussions by intriguing participants and engaging them in non-threatening conversations through which they can learn from their own and others' experience. There is potential for further evaluation and development of theDining with Deathmenu in the future.
SYMPTOM UPDATE BOARDS—DELIVERING EDUCATION AT THE FRONTLINE
Authors: Poultney Jo , Maclaren Sarah , Raper Jude , Johnson Helen , Tallon Carole
Published: February 2014

Background

Ensuring that we all deliver the best possible care requires continued learning and updating of our skills and knowledge. The challenge for all healthcare professionals is balancing the need to be on the frontline delivering care with the need for professional development. Myton Hospice recognised that an additional approach for education was needed to increase the opportunity for learning and so the symptom update boards were devised.

Aim

One of the five commonest symptoms experienced by patients at the hospice was allocated to a senior clinician and they were asked to produce a board (24 inch by 32 inch) by using a variety of coloured marker pens to cover what they felt were the most important learning points about that symptom. All the information was based on the West Midland Palliative Care Physicians Guidelines to ensure we had consensus of opinion. A baseline assessment of knowledge was carried out. Each board was then placed in a prominent position at one of two inpatient units or three day hospices. The boards were accompanied by a question sheet to support their learning. Each board was kept in place for one month and then rotated round to a different unit.

Results

The boards have been very well received by all of the nursing staff in the different units. The nurses have commented they are able to find some time during the working day to absorb some of the information given or they pick up facts even whilst carrying out their day to day work just by glancing at the board from time to time.

Conclusion

Based on the enthusiasm for the boards we hope to continue developing this education tool further but await results of our assessment to determine if they have had a sustainable impact on knowledge around symptom management and if this translates into an improvement in patient care.
PROLIFIC USE OF MISLEADING ABBREVIATIONS BY HOSPICE HEALTHCARE PROFESSIONALS
Authors: Bell Sarah
Published: February 2014

Background

The use of abbreviations is widespread amongst healthcare professionals, despite studies showing they can be misleading and lead to medical errors. For example, SCC is used for both spinal cord compression and squamous cell carcinoma. Junior hospice staff often come from a generalist background and may interpret abbreviations as having different meanings from those intended.

Method

In order to evaluate the use of abbreviations at one hospice, a list of abbreviations were approved as being in standard use. The multidisciplinary notes from ten admissions were audited for non-approved abbreviations. Using the results of the initial audit, the approved list of abbreviations was revised and a limited duration hospice education programme was undertaken. A year later a further audit of abbreviation use in the notes was undertaken.

Results

The initial audit found that 108 different, non-approved abbreviations were used on 735 occasions. Several abbreviations had more than one meaning, and the intended use and meaning varied significantly between individuals and disciplines. Disappointingly the re-audit showed only a 14% reduction in the use of non-approved abbreviations. This appeared to be particularly associated with junior doctors in short term posts.

Conclusion

The use of potentially unsafe and misleading abbreviations is a prevalent and entrenched practice in hospice staff. Due to high junior doctor turnover, hospices need to develop rolling educations programmes to reach temporary as well as permanent staff.
CAN JUNIOR DOCTORS LEARN ABOUT PAIN MANAGEMENT THROUGH E-LEARNING?
Authors: Srivastava Leena , Lee Mark
Published: February 2014

Background

The management of serious life limiting illnesses spans across all specialities in medicine. One of the crucial goals for both patients and professionals is the effective management of pain. It is therefore vital for all doctors to have an insight into the basics of pain management.

E-learning is an innovative way of teaching. It provides flexible access to learning which can be used to target a wide range of doctors.

Aim

To evaluate the effectiveness of e-learning in improving the pain knowledge of Foundation 1 doctors.

Method

Foundation 1 doctors in Sunderland Royal Hospital were recruited in August 2010 at their induction programme. An e-learning module was constructed based on their curriculum and regional guidelines. The module started in November 2010 for 1 month. Pre and post module questionnaires as well as evaluation forms were completed by learners.

Results

14 foundation doctors initially agreed to participate in the module. 36% completed the course. The mean pre-module score was 62% (95% Confidence interval 53–70%). The mean post-module score was 77% (95% confidence interval 67–86%, P=0.042). There was also a mean improvement of 1.0 point on the Likert scale evaluating confidence in pain management.

Discussion

Our results have shown that an e-learning module on pain specifically targeted to foundation doctors can improve both confidence in different areas of pain management as well knowledge. There was however a high attrition rate at 64% despite regular contact. The motivation of learners and their inherent interest may account for this.

Limitations

Questions in the pre and post module questionnaires have not been formally validated.

Conclusion

This study has shown that it is possible to improve the pain knowledge of foundation doctors through an e-learning package. Barriers in accessing e-learning need to be evaluated to target a wider range of doctors.
‘BEING WITH YOU’. EVALUATION OF A NOVEL ‘VOLUNTEER COMPANIONSHIP TRAINING PROGRAMME’ FOR SUPPORTING END-OF-LIFE CARE WITHIN AN ACUTE HOSPITAL SETTING
Authors: Mayland Catriona , Gent Miriam , Raj Julie
Published: February 2014

Background

Although the value of hospice volunteers is widely recognised, their role within the hospital setting is less established. An end-of-life volunteer companionship programme was established within an UK hospital to help support dying patients and their families (provision of ‘sitting’ service and psychological support).

Aim

To assess the effectiveness of a two-day volunteer training programme.

Methods

Fifteen hospital volunteers were recruited due to length and experience of service; a further two through personal expressions of interest. A questionnaire (assessing knowledge, confidence about communication and support skills) was given: pre-training; 2 weeks post-training; and 3 months post-training. Each question (n=17) had 5-point Likert-scale response options (1=strongly disagree, 5=strongly agree). Free text response boxes were provided.

Two further cohorts of volunteers have been recruited (total n=30) and additional results are forth-coming.

Results

From the initial 17 volunteers, 14 were female with ages ranging from 19–70 years. Statistically significant improvements were seen across all knowledge scores post-training and were sustained after 3 months.

Volunteers were confident about their communication skills, with all question items (bar one) having initial mean scores of >= 4.38. Their responses showed least confidence in their ability to answer ‘difficult’ questions (mean score 3.94). Although all scores improved post-training, none showed statistical significance.

Volunteers were confident in their abilities to support families (baseline mean score 4.31). For all other support skills, post-training all question items showed statistically significant improvements. Except for spiritual support, confidence levels were sustained at 3 months.

Free-text comments supported the value of the training programme for their work with dying patients and their families.

Conclusions

With careful selection process, a short training programme covering pertinent end-of-life care issues is effective in providing volunteers end-of-life care knowledge and skills.
LESSONS FROM FOUR COUNTRIES IN SUB-SAHARAN AFRICA IN DEFINING AND DEVELOPING INTEGRATED MODELS OF PALLIATIVE CARE
Authors: Downing Julia , Leng Mhoira , Namukwaya Elizabeth , Murray Scott , Atieno Mackuline , Grant Liz
Published: February 2014

Background

The THET (Tropical Health & Education Trust) partnership project onStrengthening and integrating Palliative Care into national health systemscommenced in 2012. The project aims at enhancing the provision of palliative care in Kenya, Rwanda, Uganda and Zambia through the integration of palliative care into existing services within 12 hospitals and their associated community hubs.

Aims

An important component of the programme was to capture the evolution of the models of integrated palliative care developed in each of the 12 hospitals.

Methods

We conducted a baseline assessment, ongoing review and dialogue with regards to the vision for palliative care service provision to help map the process. For each hospital a matrix was developed which built on the core internationally accepted components of a model of care e.g. staffing, setting, services provided, types of patients seen, referral process, management of patients, integration within the health systems etc.

Results

The process of defining and developing a model of care was unique for each setting, and was fluid and constantly changing. Different hospitals were able to articulate different components of the model at different stages, for example, some hospitals have clear visions for palliative care but are uncertain about options and best methods of implementing their visions. An important component of the model was mapping of the referral networks, which was challenging.

Conclusion

The process of defining and developing a model of integrated palliative care go hand in hand, changing over time. Defining a model is challenging, but integral to the development of that service. Support is needed to services to do this, and the model will evolve over time. Strengthening this process and providing evidenced based frameworks from similar settings showing health systems integration is an important means of support. Many lessons from Africa are relevant to more economically developed countries.
THE EVOLUTION OF CARING FOR DYING PATIENTS IN INTENSIVE CARE UNITS IN THE UNITED STATES FROM 1960–1980
Authors: Kongsuwan Waraporn , Keller Kathryn , Chase Susan
Published: February 2014

Introduction

Since Intensive Care Units (ICUs) appeared in the United States in the late 1950's, nurses working in them have always cared for the dying patients. A historical reflection of the evolution of caring for dying patients in ICUs would assist in care model development. To discover retrospectively how and why caring for dying patients in the ICUs has changed can support ICU nurses in the present in developing their future care of the dying.

Purpose

To examine the evolution of caring for dying patients in intensive care units in the United States from 1960–1980.

Methods

Historical research method was used in this study. Data were obtained from primary and secondary sources, including electronic databases, critical care journals, and text books. Three intensive care nurses who practiced within the timeframe participated in the oral history interviews. The data were analyzed by using content analysis. Validity and reliability were established.

Findings

The three major themes that emerged were: lack of formal preparation for care of the dying (1960–1980); increased workload and stress (1970–1980); and becoming more concerned about quality of end-of-life care (mid 1970s–1980).

Conclusion

Nurses and healthcare professionals in the United States and worldwide could use this knowledge as a source to compare and develop their future practices in care for dying patients in the intensive care units.
LIVED EXPERIENCE OF CANCER PATIENTS AND THEIR FAMILY MEMBERS IN A VIEW TO DEVELOP A PALLIATIVE CARE GUIDELINE FOR THE NURSING PERSONNEL
Authors: Savio Anu , Priyalatha A
Published: February 2014

Alleviating the problems faced by patients in their advanced stages of cancer and their families has drawn substantial public attention, but little is known about the experience of these people.

Objectives of the study

To elicit the lived experience of cancer patients

To elicit the lived experience of their family members.

To identify the needs of cancer patients and family members for developing a palliative care guideline for the nursing personnel.

Methods

A phenomenological approach using descriptive analysis was utilized to explore the human experience of the phenomena under scrutiny. Interviews were recorded and verbatim were transcribed, and they were manually analysed. The Colaizzi methodological approach was used.

Results

The 10 themes identified for the cancer patients were: all change, feeling of helplessness and hopelessness, uncertainty, wishing to fulfil their role, accepting loss of control, feeling of becoming a burden, fear of death and loss, desire to live, wish to be with dear ones, developing trust in god's plan. The essence of the phenomenon, experience of living with cancer, was to regain a control over the existential changes i.e. the situation and one's own body. The 6 themes identified for the family members of the cancer patients were questioning god, living with fears and uncertainty, issues related to happiness, feeling of added responsibility, ensuring best possible treatment and care and confronting negative feelings. These six themes gave a structure presenting the essence: balancing a changed life situation in fear and uncertainty.

Conclusion

The results of this study challenge nurses to be conscious of the nature and difficulties that not only patients face but also family members are encountering. The study can increase the understanding of what it is like to have cancer in its advanced stage.
SHORT-CAM – A USEFUL DELIRIUM SCREENING TOOL IN PALLIATIVE CARE?
Authors: Porteous Anna , Lowery Lucy , MacCormick Fiona , Paxton Ann , Vidrine Jennifer
Published: February 2014

Background

The short-CAM (Confusion Assessment Method) delirium screening tool is validated in the palliative care setting. As an observational tool it is felt to be acceptable in its ease of use, however, some studies highlight challenges in its implementation.

Delirium screening using the short-CAM has been incorporated into routine assessment in five North East Specialist Palliative Care In-patient Units (SPCUs).

Aims

To assess staff opinion on the importance of screening for delirium

To determine the acceptability of the short-CAM as a screening tool.

Methods

Patients admitted to five SPCUs were regularly screened for delirium using the short-CAM. Clinical and allied health professionals participated in multi-disciplinary assessment of patients to inform short-CAM completion.

After four months of use, a voluntary and anonymous survey of staff members was conducted. Verbal rating scales were used to record staff experiences of the tool's implementation, their impression of its value and ease of use.

Results

Sixty-three doctors, nurses, allied health professionals and administrators completed the survey.

Fifty (79%) respondents believed screening for delirium to be important, however, 62% of those involved in using the short-CAM felt it did not always accurately reflect patients' condition.

Sixty-four percent of staff members found the short-CAM “not at all” burdensome to complete, however, only 44% felt the short-CAM should be introduced into routine care. Ten percent of respondents did not feel it should be introduced and 46% were unsure.

Limitations

Completion was voluntary and time limited, creating potential bias in responders.

Conclusions

The majority of health professionals believe screening for delirium to be important in the palliative care setting, however less than half believe the short-CAM should be introduced into routine patient assessment. This is likely to be multi-factorial, relating to paper-work burden, limited perceived impact on patient care and lack of confidence in this tool to reflect a complex patient group.
AUDIT OF A SPECIALIST PALLIATIVE CARE TRIAGE ADVICE LINE WITHIN SOUTH TEES
Authors: Sealy Trish , Perry Fiona , Stockdale Stacey
Published: February 2014

Background

South Tees Community Specialist Palliative Care Team (SPCT) provides Specialist Palliative Care support to a diverse population across the Middlesbrough and Redcar/Cleveland areas. Data collection in recent years has shown increasing pressures of telephone calls from generalist professionals requesting clinical advice/discussion. In 2011 an advice line was created using an office-based Clinical Nurse Specialist during working hours to co-ordinate and deal with telephone work. Alongside implementation of the System1 computerised patient record system within the team and across the locality it was felt this would provide a more controlled and consistent environment for the provision of timely and reliable advice with immediate access to written confirmation and a more readily available governance trail.

Aims

An audit was carried out with the intention of providing feedback to support the maintenance and development of the service. Questionnaires were sent to every user of the service who consented during a defined period with responses returned anonymously to the audit department within the trust.

Results

21 responses were included in the analysis of which 19 were fully completed with a range of 12 different professional roles across health and social care represented. 19/19 were satisfied with the response time and 17/17 whose enquiry regarded direct patient management felt that the advice received helped them to manage that patient more effectively. 8/19 felt that without advice the patient may have required admission to the acute hospital and 5/19 resulted in subsequent referral to the SPCT for further input. Qualitative comments were generally favourable.

Conclusions

This audit provides evidence to support the continuing need for a robust telephone advice service across South Tees. It highlighted possible areas for future development which include extension of available hours and dedicated telephone number.
SURVEY OF POTENTIAL DRUG INTERACTIONS IN ACUTE HOSPITAL INPATIENTS RECEIVING SPECIALIST PALLIATIVE CARE (SPC)
Authors: Daniel Sunitha , Hurlow Adam , Hicks Fiona
Published: February 2014

Aim

Polypharmacy is common in palliative care and is associated with an increased risk of potentially harmful drug interactions. In order to identify common interactions and explore the SPC approach to polypharmacy we surveyed hospital inpatients receiving input from an SPC advisory service.

Methodology

The notes and drug charts of 50 consecutive patients referred to the SPC team between May and August 2012 were retrospectively reviewed. Potential interactions were identified and classified according to their clinical significance as minor, moderate or major using the website http://www.drugs.com/

Results

The median number(range) of medications per patient at the time of initial assessment was 12 (5–23). In total, there were 628 potential interactions, 53 major, 505 moderate and 70 minor. Potential interactions were seen in 90% of patients and 62% had a major potential interaction. The median number (range) of major, moderate, and total potential interactions per patient was 1 (0–5), 8 (0–28), and 11 (0–32) respectively. There was a positive correlation between the number of medications and the number of potential interactions (p<0.0001). Common interactions in the major group were: QT interval prolongation (26%), enhanced serotonergic activity (18%), cytochrome P450 inhibition (16%), increased bleeding risk (12%), and reduced seizure threshold (5%). Common drugs implicated include haloperidol, cyclizine, levomepromazine, metoclopramide, opioids, benzodiazepines and ondansetron. Although at risk, none of the patients included in the study had evidence of major or moderate adverse events due to drug interactions. In only 14% (5/37) of patients taking potentially unhelpful medication, like antihypertensive, antiplatelet, and cholesterol lowering agents had SPC advised the medicines to be stopped.

Conclusion

This study demonstrates that majority of acute hospital inpatients receiving SPC are at risk of clinically significant drug interaction although the clinical importance is less clear. The study highlights the need for SPC teams to be vigilant for common interactions and to minimise polypharmacy by stopping medications of little benefit.
MY NEEDS NOW—OUTCOMES OF INNOVATIVE COUNTY-WIDE COMMUNITY NEURO-PALLIATIVE COORDINATOR POST
Authors: Scholes Carol , Garrood Liz
Published: February 2014

Introduction

Following 4 years of community neuro-palliative multidisciplinary teams in Hertfordshire, the gap of a community co-ordinator for newly diagnosed patients with rapidly progressive neurological conditions emerged as a priority.

MND71HD30PSP22MSA12CBD4

Aims

To assess the impact of an innovative co-ordinator role assessing community neurology and palliative care needs at diagnosis of five rapidly progressive neurological conditions. To examine impact on patient experience, non-elective hospital admissions and place of death.

Method

A pathway was developed direct from neurological diagnosis of five rare conditions-Motor Neurone Disease(MND), Progressive Supranuclear Palsy (PSP), Huntingtons Disease (HD), Cortico-basal degeneration (CBD), Multisystem atrophy (MSA). The community co-ordinator assessed their neuro-palliative needs soon after diagnosis, gave information, referred to appropriate community services, and then acted in a clinical consultancy role to staff and patients.

Results

Total number of patients referred and assessed during January 2012 – May 2013=139

The most frequent onward referral was to specialist palliative care=75 (54%).

31 (22%) have died, 27 (87%) in their preferred place.

Eastern Region Public Health Observatory data showed reduction in elective and non-elective hospital admissions for people with these diagnoses by over 50% in 1 year. Cost of the co-ordinator post and administrative support is 60k per annum.

Patient experience –a baseline questionnaire revealed gaps in current service. Comparison after 1 year of the service will be presented. Anecdotally it has made huge improvements to many patients' lives and improved knowledge and skills of community staff, which can be applied in managing patients outside this project.

Conclusions

The model appears to have been successful providing improved quality of co-ordinated community clinical care while reducing hospital costs. It is cost-effective and provides timely specialist support, working through existing workforce. It could be a model for managing other rare long term conditions, and to increase access to palliative care for other non-malignant conditions.
LAST YEAR OF LIFE PROJECT: BRADFORD TEACHING HOSPITALS FOUNDATION TRUST
Authors: Holmes Sarah , Price Elizabeth
Published: February 2014

Aim

to improve care of patients identified in their last year of life by increasing the number of patients identified in their last year of life; recording patients' Preferred Place of Death (PPoD); improving transfer and documentation of advance care planning decisions between primary and secondary care, and reducing inappropriate readmissions and length of stay at the end of life.

Method

Piloted on two acute medical wards, four workstreams were established to plan, implement and evaluate the project. Using a marginal gains approach, where multiple small changes produce a significant result, the team have: implemented the AMBER care bundle and linked with the Locality End of Life Register; established an End of Life Information Hub to facilitate sharing of information across boundaries; delivered an education package including multiprofessional communication skills training, role modelling on ward rounds and e-learning; improved facilities for carers of dying patients, including the provision of recliner chairs and Bradford Bags containing items to make relatives' stay more comfortable.

Results

179 patients have been entered on the End of Life Register. Of these, recording of Preferred Place of Death has increased from 4% to 88%, with 64% of those who died achieving their preference. There has been a significant reduction in number of admissions, length of stay and occupied bed days for patients in their last year of life. The speed of fast-track discharges has improved from 60% within 48 hours to 80%. An increased number of advance care planning discussions are taking place and feedback from staff at 3 months shows a sustained increase in confidence in having end-of-life conversations.

Conclusion

Although numbers are small, initial evidence demonstrates a positive impact on care for patients in their last year of life. Roll out of the project and sustainability remain challenging.
EVALUATION OF THE DOVE CENTRE, PHYLLIS TUCKWELL HOSPICE, MULTIDISCIPLINARY TEAM MEETING FOR PATIENTS WITH NEURODEGENERATIVE CONDITIONS
Authors: Dando Nicholas , Brinkworth Helen , Hawkins Helen
Published: February 2014

Background

A collaborative, cross boundary multidisciplinary team (MDT) was established in January 2012. The purpose of the meeting was to support best care for patients living with neurodegenerative disease by enhancing partnership working across the different services. The aim of this evaluation was to review the activity and impact of the meeting over the first year to identify what was going well and where the meeting could be improved.

Methods

The evaluation involved: 1)retrospective analysis of the MDT documentation including plans for nutritional and respiratory support and advance care planning, 2) review of patient deaths including preferred and actual place of death, 3) a questionnaire survey of the MDT members to quantitatively measure views on a range of statements relating to the operation of the MDT, with space for free text comments.

Results

22 patients were discussed over 10 meetings. Following discussion, plans for nutritional and respiratory support were in place for 86% and 77% of patients respectively. Plan for advance care plan was recorded in 55% of patients. 8 patients died during the year. Preferred place of care was recorded for 4 patients. 6 patients died at home or in the hospice. 9 multidisciplinary team members completed feedback questionnaires. Feedback was positive and suggested that the key goals of the MDT were being met. Improved multidisciplinary communication enhanced delivery of patient care by expediting management plans and interventions. There also appeared to be professional development by sharing experience.

Conclusion

A multidisciplinary team meeting for patients with neurodegenerative disease provides an important forum for communication and information sharing. The meeting enhances patient care by generating and expediting clinical management plans and provides a written record which is shared with key professionals. There is scope for improvement in exploration and documentation of preferred place of death and advance care planning.