End of Life Care

Introduction

The recent introduction of the Medical Examiner (ME) service changed the process for Medical Certificate of Cause of Death (MCCD) completion across Wales. This offered opportunity for local process redesign and embedding of team-based education and reflective practice, whilst reducing delays in MCCD completion for bereaved families.

Methods

We produced a process map and discussed with key stakeholders - ward teams, bereavement staff and the ME Office. We developed a team–based Proposed Cause of Death form (several PDSA Cycles) to prompt and stimulate early medical team discussion/reflection and to aid a clear formation of a proposed cause of death, in advance of ME review. This was piloted (paper form) on 2 wards (A&B) in 2022, followed by a further 3 wards (C,D&E) in electronic form in 2023. We collected data on numbers of deaths, forms completed and time between death and MCCD completion. Feedback sought from teams, bereavement, and the ME service re usefulness of the intervention.

Results

The process was successfully adopted on 2 of the 5 pilot wards. For the 2 wards adopting the process, the educational discussion and form were completed in 71% (27/38) of deaths on ward B, and 60.9% (14/23) on ward C. Time from death to MCCD completion was not significantly increased by this additional step. Feedback from adopting teams was positive, commenting on educational opportunities and improved communication between the ward and bereavement teams.

Conclusions

Facilitators of adoption were ward level consultant engagement, availability of notes and prompting of the medical team by the bereavement team. Barriers to adoption were a perception of extra work and being unable to perceive usefulness of the process. Adoption of the process led to improved team ownership of cause of death decisions, educational opportunities and better communication with the ME and bereavement teams.

Introduction

End-of-life (EOL) care in care homes includes patients experiencing "ordinary dying" from dementia or frailty, alongside those with chronic diseases and cancer. Recognizing non-specific decline is complex. The One Weston Care Home Hub (CHH) implements comprehensive EOL care, achieving 95% of deaths in the preferred place and prioritising a "good death". Whilst "Just in Case" (JIC) injectable medications are commonly prescribed, a broader understanding of prescribing patterns is useful for learning about medicines waste and recognition of dying. This study investigates the prevalence of common prescriptions and explores the need to re-evaluate anticipatory medications for care home residents.

Method

A qualitative audit evaluated EOL care prescribing practices in 100 care home deaths by examining medication management in patient notes. Data were collected retrospectively on parameters including the completion of palliative drug charts, issuing JIC medications, and the timeline from prescribing JIC medications to death. Information on medications administered within the last two weeks of life and the cause of death was also recorded.

Results

34% received no additional medications. Antibiotics were the most commonly issued medications; 31% patients received them, half in liquid form. Other prescriptions included oral or topical analgesia (21%), laxatives (9%), benzodiazepines (8%), and oral steroids (5%). Liquid preparations comprised half of the issued medications. 74% of patients had JIC medications issued a median of 23 days before death (range: 1-1244 days).

Discussion

The use of antibiotics in this cohort is complex: are they prescribed for successful treatment, or could braver decisions be made not to prescribe when recovery chances are limited? Injectable JIC medications are a timely proxy for recognizing the terminal phase, but 26% of patients who died did not have these in place. Further study is required to determine if they were indeed not needed and how many of those prescribed were used.

Introduction

Introduction of the medical examiner (ME) service has changed the process in which the Medical Certificate of Cause of Death (MCCD) is completed across South Wales. In a tertiary hospital we endeavoured to improve team ownership of medical cause of death decisions, senior involvement, and communication of this to the medical examiner service, through development of a new process and communication form.

Methods

Two PDSA cycles have been completed. With stakeholder involvement we produced a process map and developed a Proposed Cause of Death form. In 2022 medical teams on 2 wards (A&B) trialled a new process - to discuss as near as possible after death the likely cause of death and submit a Proposed Cause of Death form. We collected data on number of deaths, number of forms completed and time between death and MCCD completion. In 2023 a task and finish group developed an electronic form and piloted on a further three selected medical wards (C,D&E).

Results

Cycle 1: Mar-Aug 2022. Proportion of deaths with form completed: Ward A 0%(0/25), Ward B 71%(27/38). Time from death to MCCD completion was not increased by form implementation (3.1 days after vs 4.7 days before). Cycle 2: Aug 2023–Jan 2024. Proportion of deaths with form completed: Ward C 60.9%(14/23), Ward D 0%(0/22), Ward E 5.3%(1/19). Time from death to MCCD completion increased by only 0.6days compared to 3 control wards (5.7days vs 5.1days).

Conclusions

The process and form were successfully adopted on 2/5 wards. Facilitators of adoption were ward level consultant engagement and prompting of the medical team by the bereavement team. Barriers to adoption were a perception of extra work and being unable to perceive usefulness of the process. Ongoing work aims to improve team motivation through education and recruitment of ward 'champions', and rollout to additional wards.

Introduction:

A BMJ study suggested that 1 in 5 sick, older patients have a ‘do not resuscitate’ document and a large proportion only had this completed in the Emergency Department (ED) (1). Current ED pressures could cause greater delay in this discussion, resulting in inappropriate cardiopulmonary resuscitation (CPR). The ReSPECT form was established to bring consistency to the communication of patients wishes, including ‘do not attempt CPR’ (DNACPR) (2). This QUIP assessed the incidence of inappropriate CPR in two ED’s by investigating the proportion of CPR performed on those with a prior DNACPR or ReSPECT form.

Method:

Data was collected retrospectively from cardiac arrests in two ED’s between the 1st of January 2023 and the 17th of November 2023. The three parameters assessed were the number patients undergoing CPR, number with prior DNACPR/ReSPECT forms, and how often CPR occurred within 30 minutes of patient arrival. Hospital A used ReSPECT forms, whereas Hospital B did not.

Results:

Over the assessed period, CPR was performed on 21 patients at Hospital A. Of these, 19% had prior DNACPR/ReSPECT forms and 43% of CPR was within 30 minutes of patient arrival. 10 patients received CPR at Hospital B. Of these, 0 patients had prior DNACPR/ReSPECT forms and 40% of CPR occurred within 30 minutes of patient arrival.

Conclusion:

Hospital A performed CPR on more patients with prior DNACPRs compared to hospital B. Occasionally, these DNACPRs were on the GP portal but were not easily accessible in the hospital setting due to the hospital’s paper-based notes system. Both sites performed CPR on a similar proportion of patients within 30 minutes of admission. This highlights the importance of prompt decisions, communication and the need for community discussion with documentation that is easily accessible across healthcare settings.

Parkinson's Disease (PD) is a progressive neurological disorder for which there is currently no cure.  Palliative care should be discussed as part of PD management, both to empower patient understanding and expectations of their condition and to avoid unnecessary hospital admissions

Results from the 2022 Parkinson’s UK national audit,  found that the elderly care PD service in York was underperforming in having advance care planning (ACP) discussions with PD patients. The aim of this quality improvement project is to further review ACP discussions on a larger sample size and improve practice in this area.

Our sample included 100 people with idiopathic PD within the Vale of York who had been seen by a PD specialist in the month of November. Clinic letters from all PD specialist involvement were read, alongside any letters from other specialities, discharge letters from hospital and general practice encounters to look for any documentation of ACP discussions.

Results showed that 82 patients had no documentation of any discussions on ACP. This population included patients in nursing homes, needing package of care, patients with Rockwood frailty scores >6 and patients showing signs of deterioration in their condition.

It is clear from the data that these discussions are not occurring as often as they should.  Simply doing this QIP has raised awareness within the team and anecdotally, improvement in performance has already been noted.  Further discussion and presentation of the QIP findings are to be presented at clinical governance meetings to provide further education.  Data will then be reaudited. 

Further change options following discussion and education could include clear documentation strategies for ACP helping to link between primary and secondary care. It should be noted that our service does not provide a Parkinson’s nurse who would often instigate ACP discussions.

Introduction

40% of 1056 patients discharged from our acute geriatrics ward met Gold Standards Framework (GSF) Prognostic Indicator Guidance for Recognition of Patients approaching End of Life (EOL). 92% were not referred to Community Palliative Care (CPC) services, meaning patients’ needs were not fully met and other services over-stretched. This project aimed to achieve a 10% reduction in missed referrals.

Methods

Highlighting the missed referral rate enabled engagement of key stakeholders including ward and palliative care multidisciplinary teams. This 12-month project comprised four PDSA Cycles: 1. Raising awareness of GSF and CPC through ward-based teaching; 2. Development of posters outlining referral criteria and pathways; 3. Hospital-wide survey of doctors’ understanding of treating patients approaching EOL, with real-time feedback on GSF and CPC; 4. Formal departmental and year-group teaching sessions. The outcome measure was the percentage of patients meeting GSF criteria who were not referred to CPC, as determined by retrospective analysis of discharge letters. Readmission rate was calculated as a marker of quality of life (QoL) and to assess the impact of missed referrals on the Trust.

Results

Interventions led to a sustained reduction in missed referrals (72% from 92%). Certain diagnoses are more readily referred, metastatic malignancy for example, 9x more frequently than advanced Parkinson’s. Patients meeting criteria averaged 3 admissions in the preceding year (compared to 1.7). Of those meeting criteria and still alive, patients not referred averaged 1 re-admission within 6 months compared to 0.3 when referred.

Conclusions

Missed CPC referrals impact patient QoL and increase the burden on acute inpatient services. Significant benefits could be seen if these findings are extended to other inpatient wards. There is also a need for education about the palliative stage of non-malignant diseases such as Dementia and Parkinson’s. Future steps include technology-based active screening of inpatients to facilitate referrals.

Background End-of-life (EOL) care aims to anticipate, prevent and treat symptoms experienced by the dying patient. An EOL care strategy described by King’s Health Partners (KHP) outlines the ‘ICARE’ framework, created from the five priorities for the dying patient, giving generalist hospital teams a memorable prompt to consider holistic needs of patients. We aim to reconcile performance of Acute Medical Unit (AMU) in providing EOL care, against KHP's framework, to reduce patient suffering and improve care. Methods A prospective review was performed of all AMU deaths from March-September 2021, reviewing resuscitation status and EOL medications. Sudden deaths for full resuscitation were excluded. Following review, teaching to AMU was delivered and a wall poster of the ‘ICARE’ framework was displayed. A second prospective cycle was performed reviewing deaths from March-September 2022. Results 50 deaths were recorded in cycle one. 21% (12/58) of dying patients were not prescribed EOL medications. Medication omission for 50% (6/12) of patients were due to lack of recognition of EOL. Other reasons included no consultant review, undecided resuscitation status and a missing prescription. In cycle two, 11% of dying patients (6/48 patients) were not prescribed EOL medications, all of which were due to lack of recognition of EOL. 12 deaths had EOL medications prescribed but had an inappropriate resuscitation status. Conclusion The second cycle showed a 50% reduction in deaths with EOL medication omissions, when compared to the first cycle. Reasons for medication omissions were less varied in cycle two, highlighting reduction in avoidable causes. Although not affecting patient care, a notable number of patient records had incorrect resuscitation statuses. Overall, improvement in delivery of EOL care within AMU can be seen. Future considerations involve emphasis on keeping electronic patient record up to date to avoid errors and continual provision of education to new and rolling staff.

Introduction

We plan fast-track discharges when a person has limited life expectancy and is reaching end of life. When such patients are identified, we use a simple fast-track tool to minimise the delay and reduce the need for in-depth assessments and paperwork. Despite being used very widely, there is very little data in literature regarding the indications for fast-track discharges and life expectancy of patients following discharge. We conducted this observational study to answer these questions.

Methods

We collected data over a three month period from the fast-track applications focusing on indications, length of survival post discharge and what has been communicated to the families.

Results

There were 45 discharges during the three month period. The mean age was 79.6 (range 32 – 98). Most of the applications were made from the medical wards (32), especially from the care of the elderly wards, followed by surgical and the emergency quarter. 10 patients died in the hospital before their discharge could be processed. 17 patients went home, 14 went to a care home and 4 went to a community setting. 23 patients had malignancy, 11 had end organ failure, 6 had advanced dementia, 3 had stroke and 2 had fracture neck of femur. After excluding the patients who died in the hospital, the mean survival following discharge was 15.9 days (1-77 days) and 5 patients were still alive at 90 days. Evidence for good communication with families was lacking from the application forms.

Discussion

Malignancy is the most common reason for fast-track discharges. Even though many patients and families think that end of life means only days or weeks, many survive much longer. We need better documentation regarding communication with patients and families regarding diagnosis and prognosis. 

Introduction: The COVID-19 pandemic has resulted in many people experiencing bereavement in challenging circumstances. In April 2020 at a large London Trust, a “Bereavement Welfare Hub” (BWH) was established to offer support and advice by telephone to relatives and carers of all adults who died as inpatients. Data from these calls has been used to examine and learn from experiences of the bereaved at this time.

Methods: Data from BWH call records regarding 809 adults who died at the Trust in March - May 2020 were collated and analysed quantitatively. A random selection of 149 call records were examined using thematic analysis.

Results: 809 adults died at the Trust between March and May 2020. The mean age at death was 76 (SD=14) and 86% of deaths occurred on medical wards (outside intensive care). Bereavement calls were completed in 663 (82%) of cases. From analysis of call records, several themes that influenced the bereavement experience were identified. These included support from family and community, communication and contact with the dying person, support from bereavement services and ability to carry out usual rituals associated with dying.

Conclusions: Age is a significant risk factor for death from COVID-19 and the majority of deaths have occurred on medical wards. Improving hospital care of dying patients during the pandemic or at any time is relevant to geriatricians and other healthcare professionals working with older people. Our analysis identifies several factors which positively or negatively influenced the experiences of people bereaved during the first wave of COVID-19. From these findings, recommendations have been made which have the potential to improve the bereavement experience, particularly during the pandemic era.

Introduction

The therapeutic benefits of narrative in terminally ill patients is widely studied and evidenced in the research literature. The Hospice Biographers are a charity offering a professional free service for end-of-life patients the opportunity to audio-record their life story in a memory stick and to keep copies for themselves and for their families. The objective of this qualitative study is to explore the experience of a group of people either recording or listening to an audio-biography.

Methods

Five semi-structured in-depth interviews with terminally ill adults who recorded an audio-biography and another interview with a family member were conducted virtually. Transcripts of the zoom interviews were coded using thematic analysis.

Results

Our findings showed that patients found talking to a trained audio-biographer provided a neutral, non-judgemental interlocutor. The biographer helped them reminisce in a guided conversation navigating their life stories in chronological order. The experience of planning for the recording varied from preparing a mind-map, to writing down some guide notes or no preparation at all. Patients reported a feeling of catharsis while telling their stories as well as being able to reflect on and analyse significant life events. However, it was challenging to convey difficult emotions whilst being mindful of how patients’ life stories might be perceived by families. Although there was a degree of uncertainty about impact of the recording upon listeners, it was felt that leaving a voice-recorded account would still be informative and beneficial. A personal narrative could also provide a wider historical account of the relevant time period. Some individuals fed back that they would have valued the opportunity to edit their recording after listening and include a visual element.

Conclusions

Recording an audio-biography in terminal illness allows patients a space for reflection and provides a valued connection with immediate family members and future generations.