Acute care resource End-of-life care in the acute care setting

Background 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 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 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.RCP website

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.Deciding Right website 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 For patients who are well enough For patients well enough to be discharged 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. 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 The focus of care should be comfort-based, avoiding unhelpful investigations and ineffective treatments Aspect of management Recommendations Medication 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 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 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 roundsDiscussion following recent deaths 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) Was this death expected? Were the patients’ priorities for end-of- life 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: – 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 websiteAssociation for Palliative Medicine’s website – e-learning that can be found on – prescribing guidance and advice that can be found by registering at

The RCP produces a series of acute care resources on a range of topics, including: 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: