1. Psychiatry Higher Training
Palliative Care and Old Age
Psychiatry Higher Training
Dr. Aoife McMahon, ST4 Old Age Psychiatry, Manchester Mental Health and Social Care Trust,
Dr. Iain Lawrie, Palliative Care Medicine Consultant, North Manchester General Hospital, Pennine Acute Hospitals, Dr. JS Bamrah, Medical Director, Manchester Mental Health and Social Care Trust
Introduction
Audit
Survey
Why should we, as Old Age Psychiatry trainees, be interested in palliative care?
Palliative, or end of life, care is a prevalent issue within our patient group. We treat patients with dementia, and other chronic illnesses, daily and are therefore involved in the management of such issues.
We can be proactive at recognising end of life, and therefore proactive in preparing patients, relatives and other professionals involved.
We can identify that this will occur later in life for our patients, and support advanced decision-making, planning for end of life, and other features of patient autonomy.
We can support, and work collaboratively with, our medical and nursing colleagues, to provide a high level of patient care.
Why am I interested in palliative care?
Working as a Core Trainee and Specialist Trainee in Old Age Psychiatry, I have had palliative care experience.
My ‘dying patient experience’ has been very variable. Although difficult to assess ‘good’ versus ‘bad’ care, carer feedback varied dramatically.
This has stuck with me, leading to questions such as ‘Can we improve patient palliative care on our wards?’, ‘Can we improve patient palliative care within the community?’.
On this basis, I undertook special interest sessions, a survey and an audit in this area.
I undertook an audit to review the practices in Manchester Mental Health and Social Care Trust Older Adult in-patient wards in terms of in-patient palliative care of patients with dementia.
This audit considered the areas of advance planning (using CQUIN, Commissioning for Quality and Innovation measures), and compliance with local and national guidelines used for palliative care.
The audit information was gathered and results assembled between May and July 2013 by myself, with support and assistance from administrative and managerial staff.
Only five appropriate patients were included within the audit. The small number of patients most likely reflects the tendency for patients to be transferred to other units, primarily an acute hospital for end of life care rather than remaining on the mental health ward. Each had a diagnosis of dementia and received palliative care to the time of death on an in-patient ward.
The results demonstrate that, in general, families are well consulted and there is good documentation of discussion with families and carers in terms of both advance planning and palliative care treatment options, although the advance decisions made by patients are not always documented.
The use of end of life care pathways was variable. All patients, but one, were placed on the Liverpool Care Pathway for the dying patient at one point. Multi-disciplinary team decisions about care were well documented. In almost all cases, there is documentation of consideration of the various aspects of the patient’s wellbeing holistically. All patients were documented as ‘not for resuscitation’.
The strength identified by this audit was with good documentation, and apparently good communication between the multi-disciplinary team and patient’s families and carers. The general approach to end of life care appears to be of a high standard.
The limitation of this audit is that only a small number of patients were considered. As above, there is also non-uniform use of end of life care pathways. However, with the recent move to stop using Liverpool Care Pathway, and for individualised palliative care, this does not present an ongoing issue in terms of future planning.
Re-audit with a greater number of patients, perhaps outside the realms of older adults and dementia, is likely to be useful.
The future of the end of life care pathway is uncertain, although a standardised trust protocol, working with local palliative care teams could be useful.
I surveyed a small number of local Old Age Psychiatry trainees in May 2013.
The survey asked:
Have you had experience of palliative care within the Old Age Psychiatry setting?
If so, what was your role within this process? 
Do you feel confident in your skills to recognise when palliative or end of life care should be undertaken/implemented?
Do you feel confident in your use/understanding of tools such as the Liverpool Care Pathway for end of life care?
Are you aware of local resources when considering end of life care?
The outcome of the survey was that, in general,
respondents felt that they had limited experience of palliative care within Old Age Psychiatry training.
People have had experience within other specialties, aiding confidence in their use of end of life care.
Trainees had little knowledge of local resources in general.
Trainees admitted that they had difficulty in recognising when end of life care should be initiated.
Conclusions
Special Interest
Sessions
In conclusion, my recent experience has been eye-opening in terms of the usefulness of close relations between Old Age Psychiatry and palliative care teams.
The above survey demonstrates that we, as trainees, have limited experience in palliative care. Trainees admit that knowing when to initiate end of life care for patients can be difficult, which can then have an impact upon patient care, and the way that we communicate with patient’s families and carers.
The outlined audit into end of life care for patients with dementia on mental health in-patient units demonstrates non-uniform use of the Liverpool Care Pathway, or local end of life care pathways; however, there is good documentation of honest, open conversations with family members and carers.
Such conversations document consideration of advance care planning and the complexities of the unpredictability of end of life care, as well as the prognostic course of the dying patient, in particular for patients with dementia. This audit demonstrates that having such conversations seems to improve facilitation of families’ experience of their dying relative.
I would advocate that we, as trainees, proactively seek further training into the provision of end of life care, the practicalities and implementation of this care, and the communication that is required with patients, families and carers, as this is most likely to improve the experience of end of life care for all.
I would advocate other trainees to organise special interest sessions with local teams. Personally, my time with the hospital palliative care team and the Macmillan nurses has been an invaluable experience.
I spent one session a week with our local Palliative Care Specialist Team, supported by Dr. Lawrie, the local Palliative Care Specialist Consultant, and the Macmillan team, for 6 months.
My objectives were: 1. To gain experience of how the palliative care team work within the acute hospital setting, including: – Ward rounds and patient reviews with the team Consultant for both in- and out-patients. – Ward reviews and understanding the role of the in-patient Macmillan team with Macmillan nurse. – Understanding the discharge planning process for the dying patient. 2. To gain experience of the community Macmillan team, including: – Home reviews with community Macmillan nurses. – Home reviews with a Speech and Language Therapist. – Accompanying the '6 Steps' Programme Coordinator on visits to local nursing homes – promoting awareness and practice of end of life care in nursing homes To follow the patient journey, and understand the communication and practicalities involved in end of
life care.
I was able to fulfil these objectives, and more, throughout these sessions.
I was able to identify the areas in which collaborative working with the palliative care team could be helpful in my own practice.
I was able to provide help and advice about the use of psychiatric medications for the palliative care patient.
Most of all, the sessions taught me about communication with the dying patient, responding to the needs of family members or carers who are going through this difficult process, and being flexible in supporting patient needs, both pharmacologically and non-pharmacologically.
References and Thanks
Department of Health. Living Well With Dementia: A National Dementia Strategy. February 2009.
National Institute for Health and Clinical Excellence. CG42 Dementia: NICE Guideline. November 2006.
Thanks to the staff on the Later Life wards, Manchester Mental Health and Social Care Trust.
Thanks to the Specialist Palliative Care Team, North Manchester General Hospital, and the North Manchester Macmillan team.
Thanks to Dr. Lawrie and Dr. Bamrah for their support, assistance, time and guidance in my palliative care experience.
CONTACT
NAME: Dr. Aoife McMahon