End of Life Care At the West Suffolk Hospital Title slide Sam Hobson Dr Rosemary Wade END OF LIFE CARE PATHWAY

End of Life Care National Strategy, July 2008 Builds on NICE Supportive and Palliative Care Guidance 2003 Drivers for change Patients want to die at home and not in hospital We can not afford to have patients in hospital who don’t need or want to be here

More patients dying at home How do we make this happen? Identify early – well before ‘last days’ Fully inform patients and their families Advanced care planning Communicate patients preferences and wishes to primary care team

Which patients ? Patients who are likely to be in their last year of life Either know on admission (GP - GSF) or diagnosed during admission Likely to have Advanced cancer Advanced heart, renal, respiratory failure Advanced neurological conditions Multiple co morbidity (frail elderly) Explain GSF 4

GPs now use, GSF – Gold Standard Framework Register of patients in last 6-12 months All GP practices – QOF points MDT meeting every 6-8 weeks Patients’ needs discussed and care planned Therefore inform GPs and refer to community nurses

WSH End of Life Care Pathway Identify Assess Address Communicate

Identify Assess Address Communicate Patients who are likely to be in their last year of life Either Known on admission (GP GSF) Diagnosed during admission HISS – End of Life Care Alert - EOLC EPRO – End of Life Care alert HISS for ward clerks EPRO for clinicians E 7

Identify Assess Address Communicate On and during admission a full medical, nursing and occupational therapy assessment involving patients family and carers. Social and occupational needs Psychological well-being Spiritual well-being and life goals Often admission process sufficient

Identify Assess Address Communicate Consider physical, social, psychological, spiritual and information needs. Make clinical decisions appropriate for prognosis. Give patient (and family) the information they need to take a full part in deciding their priorities for their care Consider referral to: In hospital - palliative care team, chaplaincy team, AHPs, specialist discharge planning etc On discharge – Specialist palliative care providers, social services, carer support, community AHPs etc Identify Assess Address Communicate

Identify Assess Address Communicate To primary care on discharge EPRO discharge letter, all letters To family and friends if dying Care of the Dying Pathway LCP Into bereavement

Identify Assess Address Communicate On discharge always send EPRO End of Life Care discharge letter - A detailed discharge summary including information on patient’s diagnosis, prognosis, understanding of condition and preferences for care. Single point of access referral to District Nurses for palliative care assessment

Care of the Dying LCP Vs 12 Integrated care pathway used at the bed side to document care given to patients in their last hours and days of life.  Version 12 – to address concerns regarding nutrition and hydration and regular review – contains information leaflet for patients/relatives

End of Life Care Intranet pages New site Main pages Pathway, Identify, Assess, Address, Communication Additional pages Care after death, WSH palliative care team, Community specialist palliative care, Resources/Links page

End of Life Care Intranet pages Useful paperwork To print off and use Discharge in last weeks checklist Rapid discharge home to die LCP Preferred priorities of care document

Training programme Sam Hobson – End of Life care PND Roll out over next year LCP Vs12 and End of Life Care to each ward Governance meetings Targeted groups

West Suffolk Hospital End of Life Care Strategy To provide high quality care in accordance with patients wishes To enhance communication and co-ordination With challenge of Patients with months, weeks, days and hours to live Hospital wide – Patients in many settings, together with a range of appropriate medical and surgical care

Main messages - Doctors Identify patients Make clinical decisions appropriate to prognosis Keep patients well informed (and their families) and support patients with their decisions Make plans on discharge Communicate with GPs on discharge and outpatient letters

Questions ???