Title slideEnd of Life Care

At the West Suffolk Hospital

Sam Hobson

Dr Rosemary Wade

END OF LIFE CARE PATHWAY

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End of Life Care

• National Strategy, July 2008• Builds on NICE Supportive and Palliative Care Guidance

2003

• Drivers for change– Patients want to die at home and not in hospital– We can not afford to have patients in hospital who

don’t need or want to be here

More patients dying at home

• How do we make this happen?

• Identify early – well before ‘last days’• Fully inform patients and their families• Advanced care planning• Communicate patients preferences and wishes to primary

care team

Which patients ?

• Patients who are likely to be in their last year of life• Either know on admission (GP - GSF) or diagnosed

during admission• Likely to have

– Advanced cancer– Advanced heart, renal, respiratory failure– Advanced neurological conditions – Multiple co morbidity (frail elderly)

GPs now use, GSF – Gold Standard Framework

• Register of patients in last 6-12 months • All GP practices – QOF points• MDT meeting every 6-8 weeks• Patients’ needs discussed and care planned• Therefore inform GPs and refer to community nurses

WSH End of Life Care Pathway

Identify Assess Address Communicate

Identify Assess Address Communicate

• Patients who are likely to be in their last year of life• Either

– Known on admission (GP GSF)– Diagnosed during admission

• HISS – End of Life Care Alert - EOLC• EPRO – End of Life Care alert

Identify Assess Address Communicate

• On and during admission a full medical, nursing and occupational therapy assessment involving patients family and carers.

• Social and occupational needs• Psychological well-being• Spiritual well-being and life goals

• Often admission process sufficient

Identify Assess Address Communicate

• Consider physical, social, psychological, spiritual and information needs.

• Make clinical decisions appropriate for prognosis.• Give patient (and family) the information they need to

take a full part in deciding their priorities for their care• Consider referral to:

– In hospital - palliative care team, chaplaincy team, AHPs, specialist discharge planning etc

– On discharge – Specialist palliative care providers, social services, carer support, community AHPs etc

Identify Assess Address Communicate

• To primary care on discharge– EPRO discharge letter, all letters

• To family and friends if dying– Care of the Dying Pathway LCP– Into bereavement

Identify Assess Address Communicate

• On discharge always send

– EPRO End of Life Care discharge letter - A detailed discharge summary including information on patient’s diagnosis, prognosis, understanding of condition and preferences for care.

– Single point of access referral to District Nurses for palliative care assessment

Care of the Dying LCP Vs 12

• Integrated care pathway used at the bed side to document care given to patients in their last hours and days of life. 

• Version 12 – to address concerns regarding nutrition and hydration and regular review – contains information leaflet for patients/relatives

End of Life Care Intranet pages

• New site• Main pages

– Pathway, Identify, Assess, Address, Communication• Additional pages

– Care after death, WSH palliative care team, Community specialist palliative care, Resources/Links page

End of Life Care Intranet pages

• Useful paperwork • To print off and use

– Discharge in last weeks checklist– Rapid discharge home to die– LCP– Preferred priorities of care document

Training programme

• Sam Hobson – End of Life care PND• Roll out over next year• LCP Vs12 and End of Life Care to each ward• Governance meetings• Targeted groups

West Suffolk Hospital End of Life Care Strategy

• To provide high quality care in accordance with patients wishes

• To enhance communication and co-ordination• With challenge of

– Patients with months, weeks, days and hours to live– Hospital wide – Patients in many settings, together with a range

of appropriate medical and surgical care

Main messages - Doctors

• Identify patients• Make clinical decisions appropriate to prognosis • Keep patients well informed (and their families) and

support patients with their decisions• Make plans on discharge• Communicate with GPs on discharge and outpatient

letters

Questions ???