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Acute care resource
End-of-life care in the acute care setting
Background
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Despite best intentions, delivering high-quality end-of-life (EOL) care in the acute
environment is difficult.
Challenges faced include:
– identifying the approach of the end of life
– offering conversations on future treatment choices
– the default course of action tends to be active treatment.
80% of people would prefer to die at home, but only 45% die in their usual place of
residence.
The 2015 report from the Parliamentary and Health Service Ombudsman illuminated
how EOL care in hospitals can go badly wrong, with patients and their relatives left
unsupported.
One chance to get it right
• The Leadership Alliance for the Care of Dying People (LACDP) produced the report
One chance to get it right: improving people’s experience of care in the last few
days and hours of life in 2014.
• This report offers a comprehensive approach to management of the dying patient
in their final days and hours.
• This RCP acute care resource addresses issues regarding the care of the patient
who has been identified as being at the end of their life, throughout the final year
and months of their life.
People in the last year of life
• 90% of patients die from a previously diagnosed condition.
• The Gold Standards Framework Prognostic Indicator can
help recognition of the end of life.
• For patients who are older and frail or have advanced
progressive disease, prognostic factors could include:
– a ‘No’ answer to the question ‘Would I be surprised if the patient
were to die in the next 12 months’
– two or more unplanned admissions in the last 6 months
– poor or deteriorating performance status
– persistent symptoms despite optimal therapy
– secondary organ failure arising from an underlying condition.
End-of-life discussions
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A willingness to initiate these discussions should be demonstrated at a senior
level.
Discussions should not centre on decisions to withhold specific treatments, for
example CPR. Instead, these treatments should be placed in the context of a
conversation about the individual’s illness and what will be helpful.
An example of useful language pointers to support
such discussions, from the Australian and
New Zealand Intensive Care Society, is available on
the RCP website as an appendix.
End-of-life discussions – senior medical review
Senior medical review – best practice
Aim to include:
• an explanation that patient may be in the last year of life, with limited reversibility of their underlying condition
• a review of current treatment and care, based on patient goals
• agreement with the patient on goals for further treatment, focusing on:
• interventions to support living well
• interventions that are no longer helpful
(this may include discussions on transfer of care to another care setting and a plan for future deteriorations
and whether these should result in readmission).
All discussions and treatment plans should be documented and communicated with colleagues as part of routine
handover.
Discussions should also be offered to those identified as important to the patient.
End-of-life discussions – advanced care planning
Advanced care planning
Some patients may consent to the outcome of discussions being recorded as part of advanced care planning (ACP).
This enables a patient’s previously expressed wishes to be followed should they lose capacity in future. This is an
opportunity to explore subjects such as:
• wishes around organ donation
• specific wishes for their funeral.
Options for recording an ACP range from:
• a documented collection of preferences and values
• a legally binding advance decision to refuse treatment (ADRT)
to
• appointment of a lasting power of attorney (LPA)
The Deciding Right website provides a useful suite of documents.
Previous ACPs and discussions should be sought by speaking to the patient, those important to them, primary and
palliative care colleagues or an electronic palliative care register.
End-of-life discussions – role of specialist palliative team
• Following assessment, referral to the specialist palliative team should
be considered in patients with:
– complex symptom control or
– needs that are difficult to manage (these could include psychological, spiritual
or practical issues either in the hospital or in the community).
End-of-life discussions – communication and
consideration of care
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It is essential to document the following in the discharge communication:
• that the patient has been recognised as being at risk of dying in the next year
• outcomes from discussions about ACP, including:
• preference on place of care and of death
• information on whether orders surrounding resuscitation are to remain in place or be subject to
further review
• a request that the patient is placed on the GP end-of-life register
• information about specialist palliative team referral, if made
• information given to those identified as important to the patient.
Universal adoption and use of electronic registers is an important step towards coordination of care. One example
of this is the electronic palliative care coordination system (EPaCCS) that is currently being implemented by Public
Health England.
Last weeks and days – identifying death as a
possible outcome
Important considerations
• Identifying death as a possible outcome is important so as to allow patients a comfortable death in a place of
their choice and to allow those important to them to prepare accordingly.
• Clinicians should address reversible problems compromising quality of life while prioritising the patient’s
wishes and comfort.
• The Gold Standard Framework prognostic indicator and SPICT tool can give condition specific guidance to
identify patients approaching the end of life.
• Factors that may indicate that dying is imminent:
– Bedbound
– Drowsiness, impaired cognition
– Difficulty taking oral medications
– Reduced food and fluid intake
– Increasing symptom burden
Last weeks and days – managing the dying patient
(1)
Important considerations
• The Leadership Alliance for the Care of Dying People (LACDP) has identified five priorities for care of the
dying person:
1. The possibility of
death is recognised
and communicated
clearly; decisions are
made and actions
taken in accordance
with the person’s
needs and wishes, and
these are regularly
reviewed and
decisions revised
accordingly.
2. Sensitive
communication takes
place between staff
and the dying person,
and those identified as
important to them.
3. The dying person,
and those identified as
important to them, are
involved in decisions
about treatment and
care to the extent that
the dying person
wants.
4. The needs of
families and others
identified as
important to the dying
person are actively
explored, respected
and met as far as
possible.
5. An individual plan
of care, which includes
food and drink,
symptom control and
psychological, social
and spiritual support,
is agreed, coordinated
and delivered with
compassion.
Last weeks and days – managing the dying patient
(2)
Important considerations
• In order to deliver individual care plans and ensure that patients are cared for in the best possible
environment, a range of resources are now available, including:
– improving 24h availability of district nursing
– cooperation with ambulance services
– community-based palliative care rapid-response teams
– hospice-at-home team
– innovative care-home-based projects
– extended-hours pharmacies
– palliative care coordination centre
– 7-day hospital palliative care team services with overnight telephone advice
Last weeks and days – timely discharge for those
who wish to die at home
Important considerations
• Use of rapid discharge checklists to facilitate the transfer of care of patients who wish to die at home.
• Community nurses and GPs will be the main professional carers and responsible for coordination of care.
• Comprehensive handover is essential: the GP should be contacted by phone and have written information
sent to facilitate smooth transfer of care.
• Community nurses can provide both care and equipment.
• A package of care should be put in place, with funds rapidly accessed via fast-track Continuing Healthcare
funding.
• Other considerations may include:
– oxygen for hypoxia
– domiciliary palliative care nursing care nursing services through either the Marie Curie community
nursing service or a local hospice.
Clinical management of the dying patient
Aspect of
Recommendations
•management
The focus of care should be comfort-based, avoiding unhelpful investigations and ineffective
treatments
Medication
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Anticipatory medications to relieve pain, nausea, dyspnoea and respiratory secretion should be
prescribed.
Patients on oral opioids or anti-emetics may have these changed to subcutaneous infusions.
Nutrition
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Patients should be supported to eat and drink as able.
Decisions on assisted hydration and nutrition need to be made on an individual basis.
Other
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It is of paramount importance that the following be considered as well:
– regular monitoring of clinical condition
– goals and responses to treatment
– carers’ concerns
– signs of recovery.
Professional development in EOL care –
recommendations (1)
• Hospital teams should be
encouraged to participate in
the End-of-life Care Audit to
evaluate the care that they
provide and consider areas
for improvement.
• Learning through discussion
could be achieved through
using prompts during ward
rounds or MDT meetings.
Prompts on ward rounds
Discussion following
recent deaths
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Does the patient have an ACP?
Does the patient have a valid and applicable ADRT?
Does the patient fall into one of the following
categories?
– Has advanced, progressive, incurable condition(s)
– Has general frailty and coexisting conditions such
that they may die within the next 12 months
– Has existing condition(s) as a result of which they
are at risk of dying from a sudden acute crisis
– Has a life-threatening acute condition caused by
sudden catastrophic events
(If so, discuss preferences for treatment and place of
care)
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Was this death
expected?
Were the patients’
priorities for end-oflife care known?
– If yes, were they
adhered to?
– If no, were there
opportunities for
ACP?
Did the patient have
an appropriate,
individualised plan of
care?
Professional development in EOL care –
recommendations (2)
• Other recommendations for development include:
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integration of palliative care into daily practice
active incorporation of feedback from patients and carers
referral to local palliative care guidelines as a management guide for patients
inclusion at least one learning event on EOL care in a 5-year CPD cycle.
• Other resources that can be used include:
– local and national EOL care courses on the Association for Palliative Medicine’s website
– e-learning that can be found on www.e-lfh.org.uk/programmes/end-of-life-care/
– prescribing guidance and advice that can be found by registering at www.palliativedrugs.com
The RCP produces a series of acute care resources on a range of
topics, including:
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handover
teaching on the AMU
acute oncology on the AMU
ambulatory emergency care
sepsis
acute medical care for frail older people
acute kidney injury.
All these resources, including the full version of Acute care resource: End-of-life care in
an acute care setting, can be accessed at: www.rcplondon.ac.uk/act.