End of Life Care

Background Royal Bolton Hospital is a district general hospital in Greater Manchester. In 2023, a Cardiogeriatrics service was introduced to deliver comprehensive geriatric assessment for older cardiology inpatients with frailty.

Introduction

Our aim was to evaluate the Cardiogeriatrics service with respect to the impact on end of life care for older cardiology inpatients.

Methods

Audit standards were defined using metrics for quality in end of life care. All patients between the year 2021 and 2024 aged 75 and over who died as an inpatient or within 30 days of discharge were included. Patients who died following procedural interventions were excluded. Patient’s casenotes were audited and compared before and after the initiation of the service.

Results

Casenotes for 88 inpatient deaths were audited (66 prior to introduction of the Cardiogeriatric service, 22 following). The Cardiogeriatrician initiated end of life care in 31.6% of inpatient deaths. This corresponded with a reduction in unexpected deaths from 26% to 14%, and a reduction in patients initiated on end of life care by the on-call team, from 31.8% to 10.5%. Junior doctors on Cardiology began to initiate resuscitation conversations with patients. Casenotes for 44 deaths within 30 days of discharge were audited, however no meaningful insight could be gained as there were only 6 outpatient deaths after the Cardiogeriatric service began.

Conclusion

After introduction of the Cardiogeriatrics service, there was improved recognition of patients who were approaching end of life, and more proactive management of this. As many patients audited were not seen directly by the Cardiogeriatrician, we believe the service has contributed to a cultural change in the Cardiology team more widely towards more proactive recognition and management of end of life issues in older Cardiology patients.

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. 

Background: This project is based in the geriatric department of Wye Valley NHS trust which serves Herefordshire and mid-Powys.

Introduction : In frail, older patients, cardiopulmonary(CPR) resuscitation has low rates of success. Lack of appropriately completed ReSPECT forms leads to futile attempts of CPR, repeated readmissions and patient harm. This project aims to improve patient centred advance care planning (ACP), and the quality of their documentation in the ‘clinician recommendations’ section in ReSPECT forms through development of new educational tools.

Methods: The Supportive and Palliative Care Indicator Tool (SPICT) was used to identify patients benefitting from ACP in the department. Data was collected on how many patients had ReSPECT forms and how well they were completed against standards adapted from the Resuscitation Council guidelines. Plan-Do-Study-Act(PDSA) cycle 1 was completed developing an aide-memoire (ReSPECT tool), and an interactive workshop. PDSA cycle 2 lead to design of the project poster titled ‘Revamp your ReSPECT discussions’ which was displayed on the wards, and shared on social media. PDSA cycle 3 was conducted to measure response and aid direction. Results: PDSA 1 showed 71% patients meeting SPICT criteria had ReSPECT forms. This improved to 82% by PDSA 3. PDSA cycle 1 revealed that only 32% of ReSPECT forms were completed to audit standards, by PDSA 3 this improved to 43%. The project received engagement from the wider healthcare community on Twitter/X where the project poster garnered over 36,600 views and has been shared in the trusts latest issue of safety bites.

Conclusions: Our work led to an improvement in the quality of documentation and illustrated a novel approach to communicating the standards expected when delivering patient-centred ACP. The interest received via social media highlighted the importance of sharing this experience. We plan on building on this success through wider communication of the standards.

Introduction

Improvement project in response to several bereavement meetings with families reporting concerns with communication and care received during their loved ones’ end of life care (EOLC).

Methods

Retrospective review of 79 inpatients documentation who died between August 2021-March 2022 in comparison against the Royal College of Physicians National Care of the dying audit to identify targets for intervention. Survey of 22 members of ward staff between (January-March 23) including medical, nursing, and allied health professionals to understand confidence, clinical knowledge and available resources to care for EOL patients and families.

Results

Retrospective audit showed 13.9% of families expressed concerns about EOLC received. Discussions held of the potential for progression into EOLC were 82.4% of cases and that of approaching the terminal phase of life 83.5% which is similar to the national findings of 83% and 79% respectively. There was an absence in offering holistic support to families and patients like food vouchers, parking permits, and referral to chaplaincy team at only 27.8% cases. This theme was seen in the staff survey, with 16.5% of staff suggesting offering parking permits and 15.2% suggesting food vouchers. The survey also highlighted the relative lack of confidence of allied health professionals 5.9/10 vs the remaining team average of 8.1/10 when providing EOLC.

Conclusions

The audit and survey identified gaps in patient care and communication for our ward staff. To improve quality of care, teaching sessions in collaboration with palliative care team are set to start for ward staff. To improve communication, end-of-life board was set up as visual aid for staff, patients and family as well as a proforma to standardise death verification documentation across the trust. These are first cycle interventions to help improve patients and families holistic.

Introduction:

The preference for place of death and the concept of dying in place have been subjects of debate in numerous jurisdictions. Despite the growing prevalence of ageing populations and the increasing demand for dying in place, there is a limited body of literature exploring older adults’ knowledge of dying in place and their preferences for the place of death. In Hong Kong, there are ongoing legislative efforts to revise the policy on dying in place. This study aims to investigate the knowledge of dying in place and the preferences for the place of death among older adults in Hong Kong.

Methods:

This cross-sectional study recruited 503 older adults. A questionnaire was disseminated through online social media platforms and face-to-face interview. ANOVA was conducted to compare the differences in knowledge scores among participants with varying preferences for the place of death.

Results:

Participants demonstrated a sub-optimal knowledge level (mean = 3.55; range 0-8). Notably, 54.7% of participants were unware of the existing law that regulates dying in place in Hong Kong, and 43.5% did not know about the availability of community resources to support patients who choose to die at home. The majority of participants (55.5%) preferred to die at home. Other preferences included hospital (18.9%), hospice (17.1%), and care home (8.5%). Participants who preferred to die at home exhibited a higher knowledge score (mean 3.84) compared to those who preferred to die in hospital (mean = 2.79) (F = 5.323, p = 0.001).

Conclusions:

The findings of this study provide insights that can inform the revision of current policies, the enhancement of community resources supporting dying in place, and the strengthening of life and death education targeted at older adults.

Acknowledgement:

The work described in this paper was fully supported by a fund from Hong Kong Metropolitan University (RD/2022/2.17).

Introduction: NICE guidance recommends that clinical teams should identify patients who are approaching their final year of life. It advises using tools such as the Clinical Frailty Score (CFS) to identify this cohort. Wigan has a significant proportion of severely frail patients would would benefit from this conversation. The aim of this project was to increase the percentage of patients with severe frailty who have an advanced care planning (ACP) conversation during their hospital stay. Method: Retrospective data collected from discharge letters was used to identify patients aged >65 years with a CFS ≥7 Astley ward. Exclusion criteria included patients <65 years old, patients who died during admission, patients who moved wards prior to discharge and re-admissions if within 30 days. The cohort was examined to see if firstly they had been highlighted as a patient who would benefit from ACP, and if an aspect of ACP had been completed during their admission. Results: 10 PDSA cycles were completed over the two years (2021-2023). Our data showed that teaching on ACP and dedicated Registrar sessions on the rota had the greatest impact on improving the completion of ACP discussions. While unified method of CFS assessment on admission and documentation of ACP on shared platforms did not change the ACP uptake significantly. Conclusions: Systematic approach to improving ACP in severe frailty has the potential to improve patient experience and allow them to highlight their wishes at the end of life. Despite trialling multiple activities to increase ACP uptake it was clear whole multidisciplinary team engagement is required to maximise ACP. Therefore, future cycles will examine the impact of implementing a focused approach to ward rounds. Although we have progressed towards our goal, more work needs to be done to maximise uptake of ACP for severely frail patients during hospital admissions.

Older people with severe frailty are 5 times more likely to die in the next 12 months than older non-frail people however prognosis and disease trajectory in frailty remains difficult to predict. Advance care planning (ACP) is often not fully discussed or documented due to these prognostic uncertainties, plus time/workload constraints. This can result in multiple admissions for people with frailty in the last 12 months of life and can lead to care and death in a non-preferred place. Electronic Advance Care Plans (eACP) can be useful in reducing unwanted admissions and promoting care and death in preferred location. This project aimed to improve proportion of patients receiving care in their preferred location and reduce readmission rates. Identified patients who wished to avoid hospital readmission with clinical frailty score of 6 or more and at least 2 unplanned admissions in the preceding 12 months over a 4 month period at a district general hospital in south London. ACP was discussed with patients and families and an eACP was generated. Patients were then followed up at 3 and 6 months to assess readmission rate and rate of end of life care in preferred location. 24 patients consented - 17 women, 7 men. Mean age of 88.3 Mean pre-admission frailty score of 6.1. High level of pre-admission co-morbidity with 80% having 3 or more major comorbidities. Readmission rate was 8%. One third of patients alive at 3 months all without readmission. 23 patients had died at 6 months. 13% died in hospital versus a national average of 44%. 70% died in preferred place of death versus national average of 53%. Use of electronic Advance Care plans resulted in a low readmission rate and a higher proportion of people receiving end of life care in their preferred place of death.

Background:

Clear and accurate documentation of a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is vital to ensure patients receive appropriate care and autonomy regarding their end-of-life management. Inaccuracies or omissions allow potential for unnecessary or harmful interventions to occur.

Aims/Objectives:

To produce ≥20% improvement in accuracy and overall completion of all sections of respiratory inpatient ReSPECT forms, with particular focus on DNACPR decisions, during a four-month respiratory placement. 

Methods:

Between 21/12/21-29/4/22, DRI inpatient ReSPECT forms were reviewed for completion and accuracy overall and for individual subsections. After two weeks’ pre-intervention data collection, three interventions with complete PDSA cycles (junior presentation, ward posters and emailed consultant presentation) were implemented over 11 data collection points. Interventions reminded doctors to review forms and identify/rectify errors.

Results:

Name documentation showed a 5% sustained improvement. Consultant countersignature completion improved from baseline over seven consecutive data timepoints but wasn’t sustained long-term. No intervention significantly improved overall form completeness and patient preferences remained poorly completed (all ≤30%). 100% documentation of DNACPR status at baseline was sustained throughout. However, discussion details remained poorly documented without significant improvements seen.

Conclusions:

Despite some minor improvements seen, no intervention produced sustained changes to overall completion or key sub-sections. Sample size and project duration are recognized limitations. However, these null results emphasize that current forms are not utilized as intended and that ReSPECT completion could be significantly improved. Findings have contributed to wider research by Palliative and Resuscitation teams.

Introduction

The National Quality Board published the first Guidance on Learning from Deaths in March 2017, which stated the aim of mortality review processes across NHS Trusts and provided a framework in identifying, reporting, investigating and learning from deaths in care. Homerton Healthcare NHS Foundation Trust considered how best to implement the Guidance: record mortality reviews, increase engagement within the Trust and disseminate learning.

Method

Whilst paper-based mortality reviews had already been conducted by some specialties, there was no Trust-wide process to record data and learnings. In 2018, an in-house electronic Mortality Review Tool was built by clinicians and IT team incorporating the use of CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy), a scoring methodology used to document quality of care and impact on outcome. Ongoing training for the tool is provided to medical staff and is now used by all specialties. A quarterly multidisciplinary mortality newsletter entitled “Let’s Talk About Death” was launched and is now published on the intranet, available for all members of the Trust. Anonymised clinical case examples are used to illustrate learning points and teaching on death and dying.

Results

Percentage of completion of mortality reviews across the Trust increased from 82% to 99% with the implementation of the electronic Tool in comparable quarters (Q1 2018/2019 to Q1 2022/2023). Consultant-led CESDI scores rose from 76% to 98% over the years (2018/2019 to 2022/2023). The newsletter has led to regular collaboration with all teams involved in supporting a patient with life-limiting illness; has encouraged multidisciplinary focus on dying and has provided a leadership opportunity to geriatric medicine trainees who edit the newsletter.

Conclusion

The Trust’s response to the Guidance has resulted in measurable improvement in data recording and engagement with mortality reviews across all specialties and has reinforced the culture of learning from deaths.

Introduction

Patients with frailty who have emergency admissions are at risk of mortality and may benefit from Anticipatory Care Planning (ACP). Appropriate identification, to target limited resource in an in-patient environment can be challenging. We conducted a prospective study on a cohort of frail in-patients with a hospital admission of ≥ 72 hours duration.  We aimed to evaluate the effectiveness of the SPICT tool alongside Clinical Frailty Score (CFS) as a predictor of mortality to improve our targeting of patients for ACP.

Method.

On a single day a SPICT form was completed prospectively for each inpatient on 3 hospital inpatient wards (Complex Frailty Unit, General/Orthopaedic Rehabilitation, Step-Down Unit).  Patients were deemed SPICT positive if they scored on ≥ 2 General Indicators and ≥ 2 Clinical Indicators. CFS was also recorded. Electronic records of this patient cohort were followed up for 9 months.

Results

Of 66 inpatients, 58 (87.9%) were aged ≥ 65 years and had a CFS ≥ 4. Mode CFS value = 6 (23 patients, 39.7%).  32 (55.2%) were SPICT positive; 26 (44.8%) SPICT negative.  At 3 months follow-up SPICT had Positive Predictive Value (PPV) 40.6% and Negative Predictive Value (NPV) 84.6% for mortality. At 6 months PPV = 56.3%; NPV = 80.8%. At 9 months PPV = 59.4%; NPV = 76.9%.  SPICT negative patients with CFS 6 had mortality risk of 14.3% at 3, 6 and 9 months follow-up respectively.  SPICT positive patients with CFS 6 had mortality risks of 50% at 3 months and 62.5% at 6 and 9 months.

Conclusion

SPICT is a predictor of mortality in patients with frailty during unplanned admissions to hospital of ≥ 72 hours duration.  It is now used alongside CFS for all patients admitted to our Complex Frailty Unit, identifying patients most likely to benefit from inpatient ACP on discharge.