bluuebunny/crossref_metadata_2025 huggingface dataset:
The development of a SPA pilot for specialist palliative and end of life care referrals
Authors: Garner Dawn , Pegrum Helen
Published: March 2012

The development of a single point of access (SPA) provides a quality driven (1), efficient system for ensuring that all referrals into the services are managed in a timely and appropriate way, reducing delays in the provision of care and support to all patients. The pilot SPA model is based at the Florence Nightingale Hospice and ensures that the comprehensive referral management system embraces the patient outcomes outlined within the National End of Life Strategy (2) providing communication and feedback to individual referrers regarding the outcomes of the initial referral and on going patient pathway management. Utilising a whole systems approach, improves the referral process and therefore patient and carer experience and promotes collaborative working with all service providers. It also streamlines and speeds up the process from the referrer's perspective. It is envisaged that continual review and monitoring at 6 months of this pilot project will provide quality information and data collection. This will allow the identification of any gaps in service provision and lead to an equitable county wide service that assists with meeting the QIPP(3) requirements. Referrals are made for Bucks patients to the wide variety of palliative care services within the county and surrounding area. The SPA holds the bed state for the inpatient providers and can direct urgent referrals to providers with capacity in a timely manner. A new RAG rating system has been developed which is used by the referrer to categorise patients. This enables the provider to prioritise their workload. The SPA provides a vehicle for robust data collection which will inform commissioning of palliative and EOL care in Bucks into the future.
Hospice staff perceptions of caring for patients with a non-malignant illness
Authors: Balasubramanian Sundaravadivel , Read Sue
Published: March 2012

Introduction

Palliative care nurses who have been traditionally caring for cancer patients (CP) have started to care for non-cancer patients (NCP) as specialist hospice environments are broadening their patient criteria to accept a range on non-malignant conditions outside of cancer within the United Kingdom (UK).

Aim

The overarching aim of this qualitative research study is to explore the perceptions of registered nurses working in a hospice in Staffordshire, caring for NCPs. Specifically this involved: exploring how confident nurses feel while caring for a NCPs; identifying and describing the similarities and differences when caring for this population and those with cancer; highlighting the educational needs related to understanding the natural history of symptoms and problems in non-cancer patients; and recognising nursing perceptions on what supports/disables confidence in caring for patients with a non-malignant disease.

Method

Focus groups were conducted in this qualitative research study (n=8; n=8). The discussions were digitally recorded, transcribed verbatim and analysed using content/thematic analysis.

Results

Five key themes evolved from the research, namely: the importance of preparation; the differences and similarities between treating NCPs and CPs; the importance of collaborative working was crucial; staff and patient perspectives; and the associated challenges in terms of time, skills needed and interestingly what the future holds for NCPs within the hospice context.

Conclusions

Focus groups were used successfully to explore perceptions of registered nurses around caring for CNP within one hospice environment within the UK. While there were many challenges and tensions identified, these were well balanced with the tensions of positive and constructive comments around the integration of patients with non-malignant diseases within a traditionally cancer driven organisation. Such a change in direction will impact upon how staff manage this within existing palliative and end of life care provision.
Hospital palliative care team survey of symptom control requirements of pancreatic cancer patients
Authors: De Vos Sarah , Badgery Karen , Noble Sophie , Metcalfe Matthew , Steward William , Cooke Caroline
Published: March 2012

Background

Pancreatic cancer often presents late, treatment being palliative from diagnosis. Distressing symptoms are common, making quality of life and effective symptom control crucial.

Aim

To examine elements of care relating to symptom control of patients referred to hospital palliative care teams (HPCTs) associated with a tertiary hepatobiliary unit, to determine how the service could be improved.

Method

The Hepatobiliary MDT identified 78 patients presenting with advanced pancreatic cancer who died from July to December 2010. Data were gathered from hospital and HPCT notes using a proforma.

Results

Mean survival from diagnosis was 6.6 months. 65% were referred to HPCTs, most commonly for symptom control (84%), particularly pain (63%), nausea (12%) and anorexia (10%). 12% were referred for psychological support. 53% were reviewed as inpatients, 47% as outpatients. 78% were seen on the day of referral. Physical symptoms highlighted at first assessment were pain (67%), constipation (26%), nausea (20%), anorexia (16%) and fatigue (16%). 88% of those with pain were on an opioid at first assessment; 29% on a regular strong opioid. Others were on regular weak opioids (38%), prn strong opioids (15%) or prn weak opioids (6%). The HPCT recommended an increased dose in 60% of those on regular strong opioids. In 75% of others, commencing a regular strong opioid was advised. 15% of those with pain were on a regular non-steroidal anti-inflammatory drug (NSAID) when first assessed. A regular NSAID was recommended for 10% of remaining patients. 59% had jaundice, 67% of whom underwent biliary drainage procedures. 27% had proven or symptoms suggestive of venous thromboembolism.

Conclusion

Patients with advanced pancreatic cancer often have rapidly progressive disease with multiple symptoms, pain being commonest. Strong opioids were underused, possibly reflecting lack of confidence among staff. Consideration should be given to education and pre-emptive discussion, plus possible prescribing, from diagnosis.
Use of potentially sedating injectable medicine within our hospice inpatient unit
Authors: Tweddle Andrew , Midgley Corinna
Published: March 2012

The audit compared frequency of use of injectable sedatives at end of life (including range and mean doses) with the EAPC recommended start doses for actual sedation (as defined by EAPC, October 2009). The authors also looked at documentation of intent in using these medicines, and sharing of intent with patient and family. The authors looked retrospectively at notes of all patients dying in our hospice over 3 months. 53 patients died. 47 died on the Liverpool Care Pathway. Midazolam was used in 48/53 patients; levomepromazine in 18/53; phenobarbitone in 1/53. The mean dose of midazolam was 10.8 mg/24 h (range 5–30mg) and of levomepromazine was 16.1mg/24 h (r6.25–31.25mg). The dose of phenobarbitone used was 1000 mg/24 h. The mean 24 h doses, even in the last day of life, were at the lower end of the starting range for sedation (EAPC guidance). However on average two breakthrough injections were needed in that last day. The LCP documented restlessness as reason for giving. Documentation of intent was best for breakthrough injectables in patients on the LCP but poor for syringe driver choices. Documentation of explanation of intent, including (if relevant) intent to sedate was poor. In 17/53 there was documented discussion with the patient alone: some of these included family discussion too. In 21/53 there was no documentation of any discussion. Our audit shows breakthrough restlessness as common on the last day of life, and raises concern that we are too cautious in our syringe driver dosing. We do not document intent and discussion of intent well. Better articulation of intent in using these drugs, with patients, families and in the notes may help more confident prescribing. The authors plan to improve documentation, including hopes for (intent in using) these drugs, and sharing of intent as our standard, with hope that better symptom control is achieved.
Planning the first national end of life care survey
Authors: Hunt Katherine , Shlomo Natalie , Addington-Hall Julia
Published: March 2012

Background

The End of Life Care Strategy highlighted a need to evaluate care experiences by accessing the views of those who use end of life care services. The Strategy identified the Views of Informal Carers – Evaluation of Services (VOICES) questionnaire, which is completed by bereaved relatives, as a potential method of evaluating these experiences. The DH commissioned this study to explore the feasibility of a national VOICES survey.

Aims

To develop the most appropriate methods for a national end of life care survey by considering recruitment, sampling, online methods, ethics, increasing participation and support for participants.

Methods

VOICES was re-designed following user/professional discussion groups and analysis of existing VOICES datasets. 1422 deaths registered in two PCTs were identified by the Office of National Statistics using stratified sampling methods. Coroner-registered deaths were excluded. Deaths were assigned to one of two trial groups to determine the most appropriate recruitment approach (opt-in vs opt-out). Online completion was offered to all informants. Local organisations representing minority ethnic groups collaborated in publicising the survey, interpreting services were provided and advertising posters were translated into five languages. A series of support structures was initiated.

Results

Response rate was 33% and response was significantly higher in the ‘opt-out’ trial group (40%, p<0.001). There were no complaints in either group: only two informants called the support line. 19% of responders completed online. Minority group responses were low. As planned, data weighting was used to account for non-response bias. Excluded coroner-registered deaths were significantly different to included deaths on a series of parameters.

Conclusions

The opt-out method is the recommended recruitment approach. Experiences of minority groups should be gathered using alternative methods. Coroner-registered deaths should be included and data should be weighted. VOICES detected differences between PCTs. It will be used in 2011/2012 together with these methods in the first national end of life care survey.
Achieving preferred place of care or death
Authors: Kreeger Lulu , Smith Karen , Tame Gillian , Todd Jennifer
Published: March 2012

Background and aims

Studies support that the majority of patients want to die at home, yet in London, 66% die in hospital and Nationally, only 35% die in their home/care home. We therefore audited referrals to the hospital palliative care team over a period of 6 months, looking at documentation of and outcomes for preferred place of care/death (PPoC / D). Reasons why preferences were not achieved were documented using a locally adapted version of a model devised by the Health Sciences Research Institute, University of Warwick to measure the constraints to enabling patients to die at their preferred place (Mundayet al2009).

Results

83% of patients had a record of PPoC/D. 79% of patients who expressed a preference achieved this. Unpredictability of illness/rapid deterioration and lack of recognition of the potential for dying, were the main barriers that prevented patients achieving their preferences (41% of patients). For the 17% of patients where there was no record of PPoC/D, 45% was due to cognitive impairment and 31% due to rapid and unexpected deterioration. For patients where rapid and unexpected deterioration was the main factor to not recording/not achieving PPoC/D, discussions had not taken place prior to admission in the acute illness.

Conclusion

Better identification of the potential for dying through the use of models such as the Gold Standard Framework in acute hospital's, might reduce barriers to achieving PPoC/D. Conversations about the future and about preferences can be initiated once the potential for dying is recognised. There is also a wider societal need to encourage more open discussion of these difficult issues and thereby address the taboos that surround attitudes towards death and dying to support decision making at the end of life.
A solution to the problem of clinical supervision for lone allied health professionals within a hospice setting
Authors: Andrew Inga , Worsfold Caroline , Storey Frances , Tibbett Sue
Published: March 2012

Background

Clinical supervision has long been an integral part of practise within the nursing profession, and more recently with allied health professions, the benefits of which have been demonstrated in the literature. Within the Hospice setting, allied health professionals (AHPs) often work alone within their professional group. During informal discussions, AHPs at St. Benedict's Hospice found they were experiencing similar challenges and changes to their clinical practise.

Aims

To establish a peer-led, AHPs, clinical supervision group. Method: All AHPs working for the Hospice, were invited to attend; chaplain, occupational therapist, physiotherapist (community), physiotherapist (Hospice), lecturer/practitioner, pharmacist, social worker. The social worker declined to participate due to different management structures. Monthly, hour long meetings were planned, with each member agreeing to facilitate sessions on a rota for a year. A basic structure was established, including that brief notes would be taken on the following; What were the issues/problems? Analyse the event Proposed actions following the event What is the main learning taken away from the event?

Outcomes

Over the first year the mean number of participants per meeting was 4 (66%). The percentage of meetings participants attended ranged from 100 to 38%. The brief notes demonstrated participants sent apologies if unable to attend. After a year, participants all gave positive feedback, particularly about the benefits of supporting one another through times of great change within the NHS. The group was keen to continue and formally agreed an ‘AHPs clinical supervision contract’ including details of; ground rules, structure, documentation and evaluation. The success of the group continues, the mean percentage of AHPs at meetings this year is 75%.

Conclusion

This well attended model of multidisciplinary clinical supervision could prove to be a solution to the problem of supervision for lone allied health professionals within a Hospice setting.
Setting up an end of life group for a health and social care economy: start small, aim big!
Authors: Wenham Sarah , Whitfield Andrea , Au Gillian , Martin Michelle , Martin Michelle , Smith Kathryn , Salt Susan
Published: March 2012

Background

The End of Life (EoL) Strategy (2008) recommends a care pathway approach for commissioning and delivering integrated EoL health and social care (H&SC) services. The historical development and redesign of services within a large healthcare economy in the North West of England led to varying standards of EoL care provided by two primary care trusts, two local authorities, one acute hospital trust, one integrated Specialist Palliative Care Team and one out-of-hours service. With the proposed changes to commissioning and service provision, along with the current economic climate, the structure of services was again under redesign. This provided an opportunity to influence the strategic and operational direction of EoL services within the locality.

Aim

To set up an EoL Group for the H&SC economy.

Method

In order to facilitate partnership working, a small EoL operational group including key representatives from all the local stakeholder organisations was established. This group quickly demonstrated achievements in: • EoL care pathway design • Cross-organisational production of collaborative EoL guidance and documentation • Improving coordination and communication systems • Novel education and teaching initiatives This group was invited to put forward their vision, strategy and priorities for EoL care to the overarching H&SC Board for the locality.

Results

The vision and strategic priorities for the new EoL Group will be presented in detail, along with the action plan to facilitate seamless EoL care across the H&SC economy. Facilitating factors, barriers and key points learnt during the process will also be discussed.

Conclusion

The ability of a small number of dynamic individuals to influence and direct the strategic structure of EoL care for a whole locality is demonstrated. The driving force behind this exciting opportunity was the focus, enthusiasm and commitment of every member to work together collaboratively to enable high quality EoL care for all.
Can we work across the boundaries? Hospital and community services working together
Authors: Owens Maria , Smith Clare , Stevens Anna-Marie , Riley Julia
Published: March 2012

Background

There is an expressed preference by the general population to die at home, however in the UK 58% of people die in hospital. The Royal Marsden NHS Foundation Trust, with the co-operation of their Community Partners, has employed a case conference model to support patients achieving their preferred place of death (PPD). Patients with no further oncology treatment available are offered a case conference in their homes where a Clinical Nurse Specialist (CNS) from the hospital hands over to the community professionals in the presence of the patient. The service is called Hospital2Home (H2H). The belief is that by working together, with the patient at the centre, communication and co-ordination will improve, ensuring the patient is in the right place with the right people despite their changing condition.

Aims

The aim of this audit is to evaluate the H2H service in terms of case conference length, attendees, issues discussed and outcomes (place of death and achievement of PPD). Methods: This is an audit of all conferences over a 4 year period. Data was collected during routine assessments by the H2H staff. Analysis included; demographics, attendees, issues discussed and place of death.

Results

Of 308 case conferences 270 of the patients have died. Case conferences were attended by: Patient 92%; Carer 97%; GP 78%; DN 89%; CNS 87% and Social worker 11% Discussions included: pain 93%; other symptom control 99%; functional issues 96%; psychological issues 93%; social issues 95%; spiritual religious issues 22%. The majority of case conferences (70%) lasted under 1 h Place of death: home 47%; hospice 36%; hospital 10%; nursing home 6% and other locations 1%. Overall, this equates to 83% congruence between actual and preferred place of death.

Discussion

Collaborative working across organisational boundaries is possible and can improve PPD outcomes at the end of life.
Supporting hospice community staff with controlled drug management processes
Authors: Starnes Gina , Bunn Ray
Published: March 2012

Background

St Catherine's Hospice (StCH) Community team provides clinical advice and practical nursing support for palliative care patients living at home as part of shared care arrangements with the patient's primary care team. Following on from Accountable Officer work undertaken within the hospice Medicines Management Group, a significant gap in the support of community nursing staff from the hospice in the management of controlled drugs (CDs) was identified. Unlike in the inpatient setting, few guidelines incorporating regulations and Care Quality Commission outcomes could be found that explained processes for safely managing CDs in the home. The hospice catchment area spans two counties and Primary Care Trusts. The guidelines available within the community for the teams from the hospice to refer to regarding safe and supportive practice were inconsistent.

Aim

Produce clear guidelines for hospice community teams on the safe handling of CDs in the patient's home. Document CD processes on appropriate locality specific paperwork, ideally witnessed by two hospice staff.

Conclusion

The process of a second signature for a CD check is best practice and in the community setting this is achieved within a hierarchy of what is practical, safe for the practitioner and in the best interests of the patient, by either:

▶

Another member of the community team

▶

A care worker

▶

A relative/carer (if judged not to cause distress).

A StCH drug incident form is now completed and processed if errors/discrepancies are found. As part of last offices and verification of death in the home all CDs are now checked and signed off and accounted for as the hospice team leave the family. Unused CDs are returned to the pharmacy by the patient's family. If there is any concern about leaving CDs in the home a risk assessment is completed.
How many doctors? Relational continuity in end of life care
Authors: Edmonds Claire , McFatter Fiona , Leiper Martin
Published: March 2012

Background

Continuity of care is important to patients and is a key factor in providing good end of life care. Relational continuity describes the continuity of care provided by seeing the same doctor. This can facilitate difficult conversations regarding preferences for future care. A previous study of palliative care patients examined the number of doctors encountered. Since then there have been changes to medical training, limits on working hours and increased flexible working. This presents new challenges to continuity of care.

Aims

To study relational continuity for patients who received end of life care in the hospice setting. To assess the number of doctors encountered in the last 6 months of life.

Methods

A retrospective case note review was carried out for consecutive patients who died in a hospice over a 4 month period. A standardised data collection sheet was used and the number of doctors encountered noted. Encounters were identified by review of the hospital notes and documentation of a doctor's signature or an entry confirming which doctors the patient saw.

Results

Sixty-five patients were identified and of these 41 case notes were available. In the last 6 months of life, the minimum number of doctors met was 2 and the maximum 57, mean 19.Of the total number of encounters one third were with a doctor they had not met before. Patients saw more foundation doctors and consultants than speciality trainees.

Discussion

These results are highly likely to underestimate the actual number of doctors patients saw. It does not include encounters in primary care or the continuity provided by other health professionals. Some patients encounter a large number of doctors in the months preceding death. With reduced working hours for doctors, attention has focused on handover for informational continuity and patient safety; less attention may have been given to relational continuity.
Caring or uncaring: evaluation of nurses' perception of the ‘comfort box’ in an acute care setting
Authors: Smith Paula , Joanne Leung , Davis Rachel
Published: March 2012

Background

Providing high quality end of life care (EoLC) in acute care settings is often challenging. The importance of providing care and emotional support to visiting family members may often be overlooked in an effort to provide appropriate physical care and symptom management of the dying patient. At a local hospital Comfort Boxes have been used in some areas to provide patients and families with articles and material goods that may help to provide some relief during prolonged visiting periods. During an audit and evaluation of palliative care provision a review of the use of the comfort box was undertaken.

Aims

To explore nurses perception of the use and potential use of a ‘Comfort Box’ in a variety of acute care settings at the hospital. A further aim was to explore the nurses' experiences of delivery of end-of-life care in an acute care setting.

Methods

Eight focus groups with thirty-six registered nurses, healthcare assistants and student nurses were recruited from two units currently using the ‘Comfort Box’ (N=19) and two units not using the ‘Comfort Box’ (N=17). Focus groups were transcribed and subjected to a thematic analysis.

Results

Four main themes were identified: Comfort and care, Supporting patients and families, Personal and organisational issues and Future improvements.

Conclusion

Generally the ‘Comfort Box’ was seen to be beneficial to nursing staff and families where it is in use. However, there were tensions perceived in the way the comfort box could result in less interaction with patients and families. Personal and organisational resources were felt to have the potential to negatively impact on desired delivery of care. Suggestions for further education and training and simple infrastructure changes were made by the staff to facilitate good practice.
Palliative medicine in University Malaya Medical Centre: benchmarking against the minimum data set
Authors: Lam Chee Loong , Tan Seng Beng , Loh Ee Chin
Published: March 2012

Introduction

University Malaya Medical Centre is the main teaching hospital of University Malaya and admitted over 45000 inpatients in 2009. Palliative care services have gradually evolved since 2002. Services are currently provided by a team of medical specialists who manage an eight bedded inpatient ward, a hospital inpatient consultation team and weekly outpatient service.

Method

The palliative care database was reviewed retrospectively for the year 2010–2011 and basic demographic data, types of referrals, diagnostic categories and outcomes of care were collected and compared with the National Council for Palliative Care (NCPC) Minimum Data Set (MDS) report for the year 2009-2010. Only the hospital consultation and inpatient data is presently held within the database.

Results

A total of 856 (new, continuing and re-referred) inpatients were seen by the palliative care service. 44% were male (n=336) and 56% were female (n=428) and there were a considerably greater proportion of patients aged 65-74 compared with the NCPC data. Among new referrals, cancer diagnoses comprised 80% of referrals (n=591) compared with 19% (n=142) non-cancer diagnoses and 10 unrecorded diagnoses (1%). Proportionally more patients with breast cancer (17.6% vs 9%), motor neuron disease (9.8% vs 2%), chronic renal problems (21.8% vs 7%) and other heart/circulatory conditions (21.8% vs 12%) were seen compared with the NCPC MDS. More than half the patients seen by the palliative care team were discharged from hospital.

Discussion

The data demonstrates referral patterns and potential areas for further development. The need for more accurate evidence reflecting activity levels, outcomes and quality markers will be valuable in monitoring and planning future services as well as allocating resources in order to best meet the needs of the population. Further research into the local population is yet untapped and presents a huge opportunity for further work.
Transition to adulthood
Authors: McNamara Katrina
Published: March 2012

Background

Over recent years there has been increasing evidence of the diverse approaches to moving young people with life-limiting conditions from children's services to adult services. ACT, the UK Association for Children's Palliative Care led a project which ran for 3 years across the UK which aimed to support local services as they implemented the ACT Transition Pathway for young people with life-threatening/life-limiting conditions. The transition pathway aims to provide a person-centred framework to support the planned move of young people from child-centred care through to adult focused services. UK policy documents have recognised the need for special focus on transition in palliative care services.

Aims

A 3 year programme led by ACT completed in 2011 highlighted the range of services across the UK and key themes relating to the work This presentation will provide an overview of the current situation across the whole UK in relation to the transition of young people with life-limiting illnesses. It identifies where improvements have been made against a baseline position reported in 2008, on a local, regional and national basis. The presentation will also provide a brief introduction to policy developments in all 4 UK countries relating to transition.

Conclusion

There are a number of services across UK, many of whom have developed in response to a local need to provide services to young people moving from children's to adult services.
Potential impact of emotional and behavioural difficulties on accessing paediatric palliative care
Authors: Morris Peter
Published: March 2012

A network of specialist paediatric palliative care services is provided in the UK specifically to support children and young people and their families with life threatening and life limited conditions. Children and young people who present with other complex needs, and do not conform to the norms and values generally anticipated within children's hospice services, may be put at a disadvantage in terms of accessing the necessary care and support they require. This paper presents the findings of an evaluation undertaken over a 6 month period in 2010–2011 which focused on the question of whether there was equity of access to services for children & young people requiring palliative care regardless of co morbidity with other complex care needs. Qualitative methods were used including questionnaires to elicit the views of families, carers and professionals working within services, and interviews with children and young people who were currently accessing services. The key findings from the evaluation fell into two distinct categories: documentation to support system and process and training for staff in awareness and understanding of co morbid needs. This paper will be invaluable for those organisations in the UK who are either providing or considering providing specialist paediatric palliative care services. It provides an opportunity to consider the specific lessons learned from the evaluation and to link with highly experienced paediatric palliative care professionals and services to conduct further research into this specialist and essential area of provision for children and young people.
What end of life care do pancreatic cancer patients receive at a tertiary hepatobiliary unit?
Authors: De Vos Sarah , Badgery Karen , Noble Sophie , Metcalfe Matthew , Steward William , Cooke Caroline
Published: March 2012

Background

For patients who present with advanced pancreatic cancer, prognosis is poor irrespective of treatment. Good end of life care is therefore essential.

Aim

To examine specific elements of care given to patients at a tertiary hepatobiliary centre, to inform service improvement.

Method

The Hepatobiliary MDT identified 78 patients presenting with advanced pancreatic cancer who died between July and December 2010. Data was drawn from hospital and hospice notes using a proforma.

Results

Mean survival time from diagnosis was 6.6 months. 59% had jaundice, 67% of whom underwent biliary drainage procedures. The majority required repeated attempts, prolonging admission and sometimes precluding a patient from dying elsewhere. 65% were referred to hospital palliative care teams, most commonly for symptom control; pain being predominant. There was evidence of limited advance care planning. Prognosis was discussed with 55%. No patients had an Advance Decision to Refuse Treatment or Advance Statement of wishes documented in their notes. 24% died in local acute hospitals. Of these, preferred place of death (PPD) was discussed with 32%, of whom 50% indicated it was home. PPD was only discussed following palliative care team involvement. DNA-CPR forms were completed for all patients except one, who had a sudden, unexpected death. 47% died on the Liverpool Care Pathway (LCP). 12% died in the hospice. PPD was discussed with all except one confused patient for whom it was considered with the family. In all hospice deaths, the PPD was the hospice. All had DNA-CPR forms completed, and 8 of 9 patients utilised the LCP.

Conclusion

Although biliary drainage may improve symptom control, these patients needed complicated procedures, often prolonging hospital admission at a time when they were deteriorating. Despite opportunities for discussion of end of life preferences during these admissions, there was evidence of little advance care planning for hospital inpatients.
Acorn project
Authors: Temenos Jan
Published: March 2012

Background and Aims

In line with the End of Life Care Strategy (DOH 2007), the Acorn Project at Oakhaven Hospice promotes a healthier understanding of issues around death and dying, particularly among young people. The school activity weeks offer the community an opportunity to learn more about the hospice through the eyes of children and allow patients and carers a space to talk about their experiences. Implementation Macmillan Cancer Support championed the appointment of a Schools Project Coordinator in April 2011, with the expectation that part of the role would be to roll the project out to other hospices. Each school learns about Macmillan Cancer Support and the Dying Matters coalition. They consider how and what they might do to support Dying Matters week, within their school and community. They also commit to creating a display which starts at the hospice then travels to the local hospital, a nearby community location and finally back to the school. The project then developed beyond the 4 week model; Health and Social work (PHSE) teachers are supported to focus on death education to meet syllabus requirements for GCSE, AS, A level and Btec students. Lessons initiated with ‘A’ level PHSE students, led to the development of the project, ‘The hospice as a service provider’. Besides college based lessons, students visit the hospice to meet clients and receive teaching from members of the multidisciplinary team. Patients report how much participating gives them a sense of worth and purpose, so often lost for those at the end of life. Building on this work a placement scheme was developed which involves a 2 year placement where students gain experientially from working as part of the Acorn team. The Acorn Project is changing attitudes within our community.
Raising awareness of research in palliative care – the roadshow!
Authors: Woodward Amanda , Nelson Annmarie , Byrne Anthony , Moore Barbara , Evans Mim , Shankland Sara
Published: March 2012

Aim

To ensure all specialist palliative care teams are aware of research development and research recruitment opportunities and thus maximise access to palliative care research for all patients in Wales.

Method

The Marie Curie Palliative Care Research Centre, Cardiff, collaborated with the Wales Cancer Research Network and NISCHR Cancer Research Group to plan a series of roadshows with palliative care teams across Wales. Initially, a Pilot roadshow was launched at the All Wales Palliative Care Conference, Gregynog in October 2010. This tested, by peer review, the format and content of the series of roadshows planned for 2011. The pilot received constructive feedback and changes were made to ensure the roadshow content was clear and relevant to its intended audience. The roadshows took place at locations selected by the local clinical lead, at lunchtimes, and lasted 1–2 h. The panel of speakers took the audience through a research project from idea to completion, using a real life example. The audience completed feedback forms.

Outcome

Feedback was overwhelmingly positive. Several clinicians have contacted the group with their research ideas. Staff have been introduced to their NISCHR Regional Research Nurse Manager. Contact details have been collected and a palliative care database established.
Audit of minority ethnic group referrals to the specialist pyschological service for oncology and palliative care in East Berkshire
Authors: Ryninks Kirsty , Smith Paula , Bebb Katie
Published: March 2012

Background

Studies have repeatedly found that Minority Ethnic Groups (MEGs) are underrepresented among users of Specialist Palliative Care Services (SPCS). However, there is little knowledge about referrals to specialist psychological services in oncology and palliative care. From 2009 to 2010 referrals of MEGs to the Specialist Psychological Service for Oncology and Palliative Care (SPSOPC) within the Specialist Palliative Care Team (SPCT) in East Berkshire accounted for only 6% of total referrals. The MEG population in this area is between 9–40% so this would appear to reflect an under-referral of MEGs to SPSOPC during this time.

Aims

To audit all SPSOPC referrals to identify the composition (demographic, diagnostic, and reason for referral) of MEG patients referred to the team. To explore which healthcare professionals from primary care, acute care and the SPCT had referred patients into the service from April 2010 to March 2011.

Results

Overall referrals of MEGs to SPSOPC increased slightly to 8% during 2010-2011, which is still less than expected for this area. The reason for referral to SPSOPC was similar for MEGs and other population groups. This would suggest that there remains an under referral of MEG patients to SPSOPC in this area. While 50% of referrals were made by SPCT, only 4% of referrals to SPOPC were made by a GP or a District Nurse.

Conclusion

The study highlights the need to increase awareness of the availability and remit of Specialist Psychological Services for MEGs in referring healthcare professionals and potential clients. Further research with GPs and District Nurses is required to explore the reasons behind low referrals of MEGs to SPSOPC. Greater understanding of specialist services could help general service providers tailor their care more appropriately to the community that they serve.
Documentation after the death of a patient on a hospice inpatient unit (IPU)
Authors: Gregory Amanda
Published: March 2012

Background

Following a cluster of complaints relating to care after death, our incident reporting process identified that poor documentation may have led to miscommunication and that the processes for documenting essential information after the death of a patient were not always being followed.

Aim

The aim of this audit was to establish whether there was a true problem with documentation, to identify possible causes and methods of improvement.

Methods

All deaths (58) on the IPU between 1 May 2010 and 31 July 2010 were identified from the electronic notes. The auditor reviewed each individual case record focusing on the ‘windows’ which should be completed when a patient dies. These include documentation of: the medical certificate of cause of death (which generates a notification letter for the GP), completion of cremation papers, verification of death (VOED) and details of the bereavement meeting.

Discussion

Although documentation was generally good, there were significant omissions. For all deaths no indication was given as to whether the notification letter should be sent to other health professionals. Evidence of completion of cremation papers was only available for one patient. VOED was documented in 93% of cases although the documentation of who was present at the time of death was not always specific. There was evidence of a bereavement meeting after 39 deaths.

Actions

Recommendations were put into place to improve documentation including teaching to clinical staff and updated guidance on care after death. A re-audit was completed in 2011 (1/1/11–31/3/11, 59 deaths) with an improvement in most areas. There was over 90% evidence of completion of cremation papers. An indication of whether the notification letter should be sent to others was present in almost half of cases. There was evidence of a bereavement meeting after 52 deaths. There is an on-going programme of audit in this area.
Facilities offered to families and carers of patients at the end of life: audit of current practice
Authors: Zacharias Hannah
Published: March 2012

Background

Between 2007 and 2009, 49.3% of deaths in Bradford occurred in hospital. Where patients are identified to be in the last days of life, families and carers should be given the opportunity to have unrestricted visiting access, and may want to spend as much as 24 h a day in the hospital. Facilities should be appropriate to support carers' needs. The end of life care strategy has published guidance supporting the King's Fund recommendations for carer facilities at the end of life.

Aims

To determine current practice on five acute wards, of the facilities and services provided for relatives of dying patients. To assess if the facilities offered on purpose-built wards with greater numbers of side-rooms differ from more traditional ‘nightingale-style’ wards.

Conclusion

Facilities vary between wards within the trust regarding what accommodation is available for carers, in terms of access to refreshments, rest areas and sleeping facilities. Purpose built wards with more side rooms and designated quiet rooms offer a greater range of facilities such as sleeping facilities, alternative rest areas and use of a bathroom than the nightingale alternatives. Up to 93% of patients have relatives who wish to stay outside visiting hours. 45% of patients have at least one carer staying overnight; with at least 26% of patients have two or more carers wishing to stay. Drinks were offered on the ward in 93% of cases, however concessionary parking permits were only offered in 23% of cases. No carers were offered concessionary use of the dining room. Following the audit, hospital managers have reviewed hospital facilities for carers and are considering ways in which carer experience could be improved. A leaflet is in production for carers of dying patients, outlining facilities available across the trust.
Is there a role for clock face drawing in palliative care: time will tell?
Authors: Harris Dylan
Published: March 2012

Background

Several tools exist to assist screening and diagnosis of cognitive impairment, including the Abbreviated Mental Test; Mini-Mental State Examination; Confusion Assessment Method; and, clock-drawing test (CDT). There are now around 200 publications on the CDT, but largely published in geriatric medicine and psychiatry. Several variations of the CDT exist, but each typically requires the patient to draw the numbers as they would appear on the face of a clock, into a circle, and then add the arms to indicate a specified time. While clock face drawing may appear to be a relatively simple task, it actually requires several perceptual and cognitive functions: auditory comprehension, memory, planning, abstract thinking, perceptual-motor, visual perceptual, visual-motor, visual-spatial and executive functions.

Aim

To explore the role of the CDT in palliative care. Clock face drawing has been validated in various settings in psychiatry and geriatric medicine for example, screening for Alzheimer's disease in psychiatry and assessment post-stroke in geriatric medicine. The tool may also have a valuable role in palliative care, particularly in patients with complex neuropsychiatric problems. In other settings it has been found to be easy/quick to administer, not threatening to the patient, and useful as a sequential graphical assessment in clinical records. Examples of a useful role in palliative care include (A) a patient with parietal lobe metastases (in assessment of constructional apraxia), (B) delirium in a patient with cancer and hypercalcaemia (in assessment of cognitive function before and after treatment) (C) screening for dementia in a patient known to the palliative care team with advanced Parkinson's disease.

Conclusion

While most research has focused on the use of clock face drawing in psychiatry and geriatric medicine, it has a potentially useful role in palliative care. Further work to explore this area further is now planned.
‘Distress thermometer’ in a hospice – supporting holistic assessment and a possible outcome measure
Authors: Roth Lucy , Jones Sue , Hunt Kimberley , Cochrane Yvonne
Published: March 2012

Background

The Holistic Assessment of Concerns (HAC) or ‘Distress Thermometer’ is a tool identified by the North of England Cancer Network to support the holistic assessment of patients across the network. It consists of a list of 45 possible concerns. The patient highlights any problems that have troubled them recently. They then identify the three most important concerns scoring each on a distress score from 0–10. Teesside Hospice Audit Group has been exploring ways of measuring patient outcomes for a number of years. This is becoming increasingly important as the Care Quality Commission and Commissioners demand more evidence of a patient centred and effective service.

Aims

The HAC Tool was introduced at Teesside Hospice in 2010. The aims of its introduction were to improve our holistic care of patients by identifying what matters most to them and to provide evidence of benefit to patients of our management. Following introduction of the tool we reviewed its implementation in the Inpatient Unit (IPU) and Day Care at the hospice. We analysed 17 sets of Day Care notes and 20 sets of Inpatient notes to assess whether an initial and follow up tool was completed appropriately for each patient. The number and type of concerns elicited were identified and any change in score for each concern was calculated. The average improvement in score across all concerns was 1.5 in Day Care and 2.85 on IPU. Further results will be included in the poster.

Conclusion

As a result of this review we demonstrated that our interventions benefit patients at Teesside Hospice. It gives us some good patient centred evidence that our work is effective. We found the HAC was easy to complete. We plan to continue to use the HAC at Teesside Hospice as part of our assessment and planning of each patient's care.
Evaluation of a new education programme for overseas and local doctors
Authors: Watkinson Deborah
Published: March 2012

Background

Palliative care has been established for about 12 years in Singapore but is much less developed elsewhere in the Asia-Pacific region. The Department at the National Cancer Centre runs a busy hospital support service; seeing over 1400 new patients in 2010. It has always hosted a large number of visiting foreign doctors often returning to establish palliative care in their own countries. Local doctors also rotate through. No formal training programme or evaluation of the experience has been undertaken.

Aims

Eighteen months ago, in an attempt to formalise and evaluate the training, a series of standard ‘core tutorials’ were developed on foundational palliative care topics. MCQs were written based on these using various guidelines. 20 doctors were tested with the same MCQ preposting and after the tutorial completion; the typical interval was 6–8 weeks. Findings: Overseas doctors (n=6): mean preposting 51.4% (+/-12.9); mean post-tutorials 75% (+/-5.3) mean improvement 45% Local MOs (core trainees) (n=9): mean preposting 65.2 (+/-14.9); mean post-tutorials 82.1% (+/-8.81); mean improvement 26% Local ASTs (spRs) (n=5): mean preposting 79.8 (+/-8); mean post-tutorials 82.5% (+/-8.81); mean improvement 3%.

Conclusion

The results suggest all doctors benefited from the training but the overseas doctors improved most and results overall were more uniform. Clearly the tutorial learning was also supplemented by on-going clinical exposure. The learning points have been: MCQs were refined to eliminate ambiguity and to consider language difficulties for overseas doctors. Testing allowed struggling doctors to be identified and remedial support given. A more advanced MCQ has been added for end of posting testing. Progress is being made to use an IT system for online tutorials and MCQ testing to cut down on tutor time MCQs mainly test knowledge but they are helpful as part of a multifaceted evaluation to determine development during the posting.