1. End of Life issues. Kath Sartain – End of Life Lead Nurse, YFT
Jenni Lawrence – Macmillan GP Lead.

2. What we will cover. Data around End of Life.
Issues around DNAR/ ReSPECT.
What are CQC looking for?
Last days of Life document.
Advance care planning.
SPICT.

3. End of Life profiles.
Don’t worry! This is not going to be death by data. Just want you to know that it is a good news story in our area. Death is usual place of residence is highers across all ages and diseases in North yorkshire when compared to Englands as a whole. We have less people dying in hospital esp if you are over 75 years than the england average ( 38.6% vs 46.9%). We have more people dying in care homes than England ( 24.9% vs 21.8%) esp if you are over 85 and that is depsite having fewer nursig home beds per 100 poeople over 75 than England ( 3.3 beds vs 4.9 beds).
Our home deaths aare about the same as across England at 22%.
Our hospice deaths are higher 12.9% vs 5.7% for England.
We are an outlier in deaths from circulatory causes ( 33% vs 25.5% across England). Deaths from resp and cancer are similar to England rates.

4. DNACPR – Conversations & Process
2018

5. What is DNACPR for? To avoid futile/ineffective treatment
To maintain dignity in dying
To avoid distressing “brutal” treatment
Allow individuals to choose what treatments they do not want
Advance care planning
Audit what we are doing

6. Policy

7. Who decides?
Patient
Next of kin – only those with a lasting power of attorney for health and well-being
Next of Kin opinions asked to enable clinician to make best interest decision – Do not ask them to decide
Senior Clinician
MDT

8. DNACPR – Who should have one?
Patient’s wish
Patient’s wish specified in ADRT
Best interest decision where there would be no overall benefit
No clinical benefit (futility)

9. How to introduce discussion
Acknowledgment of their disease and prognosis – How are you?
Offer opportunity to discuss their treatment options – Ceiling of Care
Not just about CPR
Empower patient – joint decision making
Information to facilitate informed decision

10. Realistic Information
20% in-patients receiving CPR leave hospital alive -7% if on general ward (less likely to be reversible e,g, MI)
10% out-of-hospital survive
Usually those without chronic disease
Have a sudden, unpredictable event
Undignified
Not like TV – rib fractures, multiple cannulation attempts, electric shocks

11. Documentation Details of where, when and with whom Date and time
Summary of discussion
Signature, print name and title
Ceiling of Care

12. DNACPR version 13 Original form stays with patient
It is unlawful to make a DNACPR decision:
without consulting a patient with capacity who wishes to participate in treatment decision and good practice to involve family (Tracey )
without consulting NOK on a patient who does not have capacity (Winspear)
Original form stays with patient
Carbonated copy stays in notes
Everyones responsibility to check forms are correctly filled in

13. ReSPECT.
ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. ReSPECT is a PROCESS and a FORM. It creates a personalised recommendation for your clinical care in emergency situations where you are not able to make decisions or express your wishes.
May have seen communication in the GP newsletter. Going to be used in Hull and East Riding from April Not been adopted locally yet. YAS are accepting them. YFT stance is for DNAR to be completed. Being discussed at COCR in April as to what action to be taken in primary care.

14. Combo of DNAR and ACP.

15. Remember Effective communication usually resolves problems
Any Questions
Remember Effective communication usually resolves problems

16. Can you name your 1%?
One percent of the population will die every year. The Dying Matters campaign encourages GP practices to find their one percent. GP practices should have a palliative care register to support end of life care. This should include people with conditions other than cancer, and people with frailty and dementia who may be in the last year of life.
When we inspect we are likely to ask:
How many patients in your practice who died in the last year were included on your palliative care/GSF/QOF register (key ratio)
How many of these had non-cancer conditions?
We would expect to see a plan as to how GPs are trying to find their 1% and also how they are aiming to identify people with a non-cancer diagnosis. We would also expect there to be a plan as to how to improve end of life care for people from equality groups such as black and ethnic minorities. If a GP practice has a significant homeless or Gypsy and Traveller population we would explore how the practice provides end of life care to these groups.

17. Five priorities for care of the dying person.

18. Recognised and Communicated.
The possibility that a person may die within the coming days or hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly.
​When we inspect we are likely to ask:
Can we see documentation about a recent death you were involved in, and how you documented communication with the patient and those important to them?
Is there evidence the persons needs and wishes have been considered?
Can you think about how you would EVIDENCE that you do this? Use of last days of life document would do this very nicely….

20. Communication.
Sensitive communication takes place between staff and the person who is dying and those important to them. Training in communication, person centred approach and symptom control and services available is needed to improve care for all.
When we inspect we will:
Consider how the practice uses the palliative care register and team meetings to improve coordination and communication with others involved in a person’s care.
Ask whether practices feel they need more training in communicating with people with a diagnosis other than cancer.  
Keeping minutes from GSF meetings.
Advanced comms skills course at the hospice?

21. Involved in decisions.
The dying person, and those identified as important to them, are involved in decisions about treatment and care. GPs should support people to make choices about their preferred place of death.
When we inspect we will;
Want to understand how the practice records discussions about patients’ needs, wishes and preferences (advanced care planning discussions) and how it ensures they are enacted or fulfilled.
Ask how many of your patients died where they wished (preferred place of care) and in each setting (home, hospital, care home, hospice, other).
Ask whether an after death analysis is undertaken and any learning can be taken from when people did not achieve their preferred place of care and death.
Advanced care plans…. Links to end of life on RSS.

22. http://www. scarboroughryedaleccg. nhs
We will come back to ACP….

23. Listened to.
The people important to the dying person are listened to and their needs are respected.
When we inspect we will:
Ask how practices support the family and carers of patients at the end of life and in bereavement.
Do people still do bereavement visits? Phone calls? Do you document this?

24. Care is tailored.
Care is tailored to the individual and delivered with compassion – with an individual care plan in place. GPs should coordinate making and following an individualised care plan. Care plans should ideally be owned by the patient but recognised in all settings.
When we inspect we will:
Look for evidence of supporting patient’s individualised care plans. The patient must be involved in producing these and aware of their existence
Our frailty teams do care plans but not everyone who has died is considered frail….
EPaCCS….
Another key priorty for CQC ios seeing how vulnerable groups are being dealth with . I can talk to you about end of life in LD – comm LD team have developed an easy read care plan….

25. Find out more….
You may find the following organisations and guidelines useful to look at in more detail.
Care of Dying Adults in the Last Days of Life (NICE Guideline)
Dying Matters
End of life care for adults (NICE Quality Standard)
Gold Standards Framework
National Council for Palliative Care
One chance to get it right (Leadership Alliance for the Care of Dying People)
Six Steps to Success in End of Life Care
Treatment and care towards the end of life: good practice in decision making (GMC guidance)