Dr P Purcell Dr J Orme October 2009 Carmarthenshire Division End of Life Pathway Dr P Purcell Dr J Orme October 2009 Carmarthenshire Division

Background The integrated care pathway (ICP) for the last few days of life was implemented in primary and secondary care throughout Wales in 2000 It was led by Dr A Fowell, as part of the Welsh Collaborative Care project The primary aim of the project was to improve the care of the dying patient It is about best practice.

Guidelines/ Standards The all Wales ICP for the last days of life has been endorsed by key health publications such as: Nice Guidance on Supportive and Palliative care (2004) The Welsh Strategy document for Palliative care Services in Wales (2004 revised 2006) Needs Assessment for Palliative Care Services in Wales (2005)

All Wales Audit of the Integrated Care Pathway for Last days of life- August 2006 Detailed audit of the use of the ICP document 100 sites were audited Conclusion from the audit- room for improvement in completing all sections of the ICP

Promoting Best Practice The ICP should: Provide a single multi-professional record of care replacing existing nursing and medical notes for the period of care Reduce duplication of paperwork and provide good documentation of care Ensure daily review of patients

Why this particular audit? In 2002 following the implementation of the pathway, an audit was done by Tina Sweeney et al (Macmillan Nurse) in PPH and WWGH Conclusion: there was a reluctance from medical staff to use the end of life pathway

Why this particular audit? In 2004 Limited audit of patients on the pathway was undertaken to examine use of ICP by medical staff Small sample size In 2007 Dr Purcell under took a larger audit in WWGH Looking at the case notes of patients managed on ICP as presented at the medical mortality meeting (March-December 2006)

Findings of 2007 audit Majority of patients dying same or next day that ICP was started ICP document and medical notes being used simultaneously

2009-Aim To examine the use of the ICP by medical staff and to make comparisons with 2007 findings To identify cases where the ICP was indicated but not used

Sample & Methodology All case notes of patients who died in WWGH and PPH January 2009 were audited Total - 92 WWGH (52) PPH (40)

Sample N - 92

Patients on ICP- 20 Part 1

Diagnosis AML Down Syndrome Pneumonia, Hep B Myelodysplasia, COPD Mantle cell lymphoma CCF, AF (2) Broncho pneumonia (2) CCF Dementia, IHD LVF, IHD Old age CRF Renal Failure Mantle cell lymphoma, neutropenic sepsis, CDIFF Met cancer colon Pneumonia, COPD Ruptured Oesophagus Prostate Ca Septicaemia (Pseudomonas) 1 – Not documented N - 20

ICP start date same as last entry in clinical records? (16) (34) (10) (21) (9) (1) (3) (1)

PRN drugs written up? (18) (43) (11) (8) (13) (2)

Syringe driver written? (42) (13) (7) (14)

Syringe driver reviewed daily? (7) (6) (13) (4) (7) (2) (1)

2009 DNAR Form signed? Documented in clinical notes? (16) N = 20

Symptom Control Guidelines included? (18) (42) (11) (8) (14) (1) (1)

Summary Large numbers of patients managed on ICP dying same or next day Encouraging to see improvement in documentation

Part 2: Appropriate use of ICP Aim Identifying cases where ICP indicated but not used

Criteria used Where it is clearly stated in notes: ‘comfort measures only’ and where discussion to this effect has occurred with family PLUS ONE OR MORE of the following; Condition worsening despite Rx. efforts, increasing drowsiness and inability to take food, fluids or medication orally Extreme distress, dyspnoea, pain or agitation Noisy breathing/bubbly chest

Sample N - 92

Patients not on ICP – indicated?

% Eligible for ICP N = 92

Overall Conclusion Patients being put on pathway too close to death and therefore not benefiting from being managed on the ICP at the end of their lives Still a sizeable number of patients not being managed on the pathway

Discussion How can we improve on the numbers currently receiving EOL care through the pathway?

Discussion Recent snap shot survey of expected deaths over a 6 week period in North Wales showed a 74% use of ICP Reason for not using the ICP in the remaining 26% of cases: Lack of recognition of dying phase Patient did not fit criteria Lack of confidence in initiating ICP

Recommendation Raising awareness of ICP as a tool for quality end of life care via: On-going education and training of healthcare staff Presenting audit findings and identifying areas needing attention

End of Life co- ordinator Action Plan No. Action proposed By Whom By When 1 On going audit Dr Purcell On going 2 Regular feedback of audit results Dr Purcell & F2 On-going 3 Education & training End of Life co- ordinator Rachel Griffiths ASAP 4 Roll out new DNAR policy for Hywel Dda Sian Hall October 2009

Thank you