Download Liverpool Care Pathway for the Dying Patient

End of Life Care in Practice
www.bradford.nhs.uk/palliativecare
Session A
– Running an effective Gold Standards Framework
in practice: identifying patients; using the new
template; assessment and arranging support
Session B
– Advance Care Planning and Discussing CPR
Session C
– Managing the Last Days of Life
National End of Life Care
Strategy 2008
www.endoflifecareforadults.nhs.uk/eolc/
Locality end of life care registers
• Recommended in National End of Life Care
Strategy 2008
• Key objective in Bradford & Airedale End of Life
Commissioning Plan
‘Why create a register?’
1. Encourage identification of more patients approaching end
of life (particularly non cancer)
2. Educational tool to facilitate assessment and provision of
good care
3. Encourage advance care planning with patients/families
and clear documentation
4. Make information available out of hours
5. Identify deficiencies in care and inform strategic planning
‘How will it work?’
User friendly End of Life template in SystmOne:
• Different sections, easy to navigate between
• Streamlines recording of key information
• Allows quick creation of handover forms, DNAR form, drug
administration sheets etc
• Quick access to symptom guidelines, information leaflets etc
• The most important info will automatically transfer into
SystmOne summary +/- national Summary Care Record (eg
DNAR status, Preferred Place of Care)
‘Who will record information in the
template?’
•
•
•
•
District nurses
GPs
Community matrons and specialist nurses
Specialist palliative care services, including hospital
palliative care teams
• Other hospital staff?
Access currently confined to Renal, Cardiology, Diabetes,
A&E, MAU but interest is growing…
‘Who will access information in the
template?’
•
•
•
•
District nurses
GPs
Community matrons and specialist nurses
Specialist palliative care services
PLUS
• Local Care Direct
• Acute hospitals and Ambulance service (via Summary
Care Record?)
• Commissioners (anonymised reporting)
Introducing……..
Three triggers for Supportive/
Palliative Care
1.
The surprise question:
‘Would you be surprised if this patient were to die
in the next 6-12 months?’
2.
Choice:
The patient with advanced disease makes a choice for
comfort care only eg refusing renal transplant
3.
Clinical indicators:
Specific to each of the three main end of life groups cancer, organ failure, elderly frail/dementia
COPD
• FEV1 <30%predicted
• Fulfils Long Term Oxygen Therapy criteria
• >3 admissions in 12 months for COPD exacerbations
• Shortness of breath after 100 meters on the level or confined
to house through breathlessness (MRC grade 4/5 )
• Clinical evidence of right heart failure
• >6 weeks of systemic steroids for COPD in the preceding 12
months
Heart Failure
At least two of these indicators :▪ Shortness of breath at rest or on minimal exertion
(NYHA stage III or IV)
▪ Repeated hospital admissions with symptoms of
heart failure
▪ Difficult physical or psychological symptoms despite
optimal tolerated therapy
Renal disease
At least 2 of the following:
• Stage V kidney disease not having dialysis
• Stage IV/V with deteriorating condition
• Stage V (eGFR<15mls/min)
• Symptomatic eg anorexia, nausea
General frailty/dementia
• Unable to walk/dress without assistance
AND
• Urinary plus faecal incontinence AND
• Barthel score <3 AND
• > 10% weight loss over 6 months OR
• Serum Albumin < 25 g/ l
Parkinson’s Disease
At least two of these indicators:
•
Increasingly complex drug regime
• Reduced independence, need for help with daily living
• Condition less controlled and less predictable, with “off”
periods
• Dyskinesias, mobility problems and falls
• Swallowing problems
• Psychiatric signs (depression, anxiety, hallucinations,
psychosis)
Gold Standards : What is it ?
• Framework to improve coordination and delivery
of palliative care in the community
• Developed in 2001
• Recommended in NICE Guidance 2004
• Part of NHS End of Life Care Strategy 2008
www.goldstandardsframework.nhs.uk
Goals of GSF
Patients are enabled to have a ‘good death’
1) Symptoms controlled
2) Preferred place of care
3) Fewer crises
4) Carers feel supported, involved, satisfied
5) Staff confidence, teamwork and communication improve
Gold Standards Framework
C1 Communication:
Register – not just a list – “surprise question”, PHCT
discussion, traffic light system, Advanced Care Planning
C2 Co-ordination:
Identified GSF coordinator eg DN, named GP, patients
know they are “Gold”, PHCT discussion
C3 Control of symptoms:
Education, assessment tools, anticipating problems, links
with Specialists
C4 Continuity:
OOH Handover Form, resuscitation status
C5 Continued learning:
Opportunities PHCT, Critical Events Review, preferred vs actual
place of death
C6 Carer support:
National Carer’s Strategy, Risk assessment for bereavement
support, Advanced Care Planning
C7 Care in the dying phase:
LCP, Gold Boxes, Priority Patient status
GSF in Primary Care
• Identify patients in need of palliative care, including non-cancer
patients
– Prognostic guidance
– 3 triggers
• Set up a palliative care register of these patients
– GSF templates
• Meet to discuss, review and plan care for these patients
– Update OOH form, PPC, DNA CPR, ADRT
– Discuss symptom control, quality of life, holistic care
– Significant event analysis
How to run an effective Gold
Standards meeting
•
•
•
•
Large/small practices require different format
Consider named coordinator
Traffic lights
Discuss:
– Current patients (7 C’s)
– Deaths
– Adding new patients
– Developments in palliative care eg policy
– Can also be opportunity for education (SPC)
– Support for one another
Challenges??
If you are already doing this....
• The next step:
– Continue using GSF, review regularly, and
mainstream as a practice protocol.
– Include more non-cancer patients on the
register, to approach the predicted prevalence
figures.
– Audit regularly.
– Extend to further levels of GSF eg Advance
Care Planning, GSF in Care Homes etc.