Mayland, C.R. et al. BMJ Supportive & Palliative Care. Published Online: 17 January 2017
Background: The National Care of the Dying Audit—Hospitals (NCDAH) is used as a method to evaluate care for dying patients in England. An additional component to the 2013/2014 audit was the Local Survey of Bereaved Relatives Views using the ‘Care Of the Dying Evaluation’ (CODE) questionnaire.
Conclusions: Adopting a postbereavement survey to NCDAH appears to be feasible, acceptable and a valuable addition. On the whole, the majority of participants reported good or excellent care. A small but significant minority, however, perceived poor quality of patient care with clear and timely communication urgently needed.
This report finds that too many people approaching death are forced to spend long periods of time in hospital due to a lack of social care or alternative support options in their community. This in turn leads to increased hospital admissions and higher costs for an NHS under financial pressures.
The first version of this guide was published in 2010, this revised guide has been led by NHS Improving Quality, with contributions from The National Council for Palliative Care, Macmillan Cancer Support and NHS Trust Development Authority. It aims to provide practical advice and support for front-line clinicians and leaders for the work required to transform end of life care in acute hospitals.
Objective The quality of end-of-life (EOL) care in acute hospitals is variable and interventions to improve this care, such as EOL care pathways, are not always used. The underlying reasons for this variability are not fully understood. We explored healthcare professionals’ views on delivering EOL care within an acute hospital trust in the South West of England.
Methods We employed qualitative methods (focus groups, in-depth interviews and questerviews) within a study investigating the impact of a simple EOL tool on the care of dying patients. We invited a range of staff of all grades with experience in caring for dying patients from medicine, surgery and care of the elderly teams to participate.
Results Six focus groups, seven interviews and five questerviews were conducted. Two main themes emerged: (a) delays (difficulties and avoidance) in diagnosing dying and (b) the EOL tool supporting staff in caring for the dying. Staff acknowledged that the diagnosis of dying was often made late; this was partly due to prognostic uncertainty but compounded by a culture that did not acknowledge death as a possible outcome until death was imminent. Both the medical and nursing staff found the EOL tool useful as a means of communicating ceilings of care, ensuring appropriate prescribing for EOL symptoms, and giving nurses permission to approach the bedside of a dying patient.
Conclusions The culture of avoiding death and dying in acute hospitals remains a significant barrier to providing EOL care, even when EOL tools are available and accepted by staff.
This paper focuses on communication between hospital staff and family carers of patients dying on acute hospital wards, with an emphasis on the family carers’ perspective. The age at which people in the UK die is increasing and many continue to die in the acute hospital setting. Concerns have been expressed about poor quality end of life care in hospitals, in particular regarding communication between staff and relatives. This research aimed to understand the factors and processes which affect the quality of care provided to frail older people who are dying in hospital and their family carers.
The study used mixed qualitative methods, involving non-participant observation, semi-structured interviews and a review of case notes. Four acute wards in an English University teaching hospital formed the setting: an admissions unit, two health care of older people wards and a specialist medical and mental health unit for older people. Thirty-two members of staff took part in interviews, five members of the palliative care team participated in a focus group and 13 bereaved family carers were interviewed. In all, 245 hours of observation were carried out including all days of the week and all hours of the day. Forty-two individual patient cases were constructed where the patient had died on the wards during the course of the study. Thirty three cases included direct observations of patient care. Interviews were completed with 12 bereaved family carers of ten patient cases.
Carers’ experience of the end of life care of their relative was enhanced when mutual understanding was achieved with healthcare professionals. However, some carers reported communication to be ineffective. They felt unsure about what was happening with their relative and were distressed by the experience of their relative’s end of life care.
Establishing a concordant relationship, based on negotiated understanding of shared perspectives, can help to improve communication between healthcare professionals and family carers of their patients.
The effects of the Liverpool Care Pathway (LCP) have never been investigated in older patients dying in acute geriatric hospital wards and its content and implementation have never been adapted to this specific setting. Moreover, the LCP has recently been phased out in the U.K. hospitals. For that reason, this study aims to develop a new care programme to improve care in the last days of life for older patients dying in acute geriatric wards. Phase 0 consisted of a review of existing LCP programmes from the U.K., Italy, and The Netherlands, a literature review to identify key factors for a successful LCP implementation and an analysis of the concerns raised in the UK. In phase 1, the authors developed a care programme for the last days of life for older patients dying in acute geriatric wards based on the results of phase 0. Results of Phase 0 resulted in the identification of nine important components within the LCP programmes, five key factors for a successful LCP implementation, and a summary of the LCP concerns raised in the U.K. Based on these findings the authors developed a new care programme consisting of: 1) an adapted LCP document or Care Guide for the older patients dying in an acute geriatric ward; 2) supportive documentation; and, 3) an implementation guide to assist health care staff in implementing the care programme on the acute geriatric ward.
Reference: Development of the care programme for the last days of life for older patients in acute geriatric hospital wards: A phase 0-1 study according to the Medical Research Council Framework