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

2. 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.

3. 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)

4. 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

5. 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

6. 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

7. 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)

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

9. 2009-Aim
To examine the use of the ICP by medical staff and to make comparisons with findings
To identify cases where the ICP was indicated but not used

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

11. Sample
N - 92

12. Patients on ICP- 20 Part 1

13. 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

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

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

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

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

18. 2009 DNAR Form signed? Documented in clinical notes?
(16)
N = 20

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

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

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

22. 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

23. Sample
N - 92

24. Patients not on ICP – indicated?

25. % Eligible for ICP
N = 92

26. 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

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

28. 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

29. 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

30. 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

31. Thank you