1. Dr Tammy Angel

2. Facts Around 600,000 people die in England each year 2/3rds of them over the age of 75 66% of people have never discussed death with their loved one Most people probably want to die at home but 18% do 17% die in care homes 4% die in hospices 58% die in Acute Hospitals 54% of complaints in acute hospitals relate to care of dying/ bereavement care (Healthcare Commission 2007)

3. What does a ‘good death’ involve? Being pain and symptom free Being in familiar surroundings Control ( Kellehear 1990 ) Dignity and respect for the patient and family (Hopkinson et al 2005) Understanding the patient/ family needs (Costello 2006) Good communication (Taylor 2001)... avoiding a ‘bad death’....

4. Mr A 91 year old man Advanced dementia in NH Treated for pneumonia 1 month before Reducing oral intake.. To virtually nil Deteriorating swallow function Increasingly chesty, then very drowsy  AAU WGH Na 171, K 8.8, urea 81, creat 1015 Moribund, cachetic, died 6 hours later

5. Consequences of Inappropriate Hospital Admissions Patients at risk of dying in an inappropriate place of care, e.g. A/E Inappropriate patient transfers between nursing homes and hospitals can be very stressful for both patients and families. It can be frustrating for staff in both care settings. Transportation delays and discomfort Changing care teams/ fragmentation of care Poor communication of new care plans between all parties

6. The DOH EoLC Pathway ‘Surprise’ question – would you be surprised if the patient was to die in the next year? If not, then they are likely to need supportive/palliative care.  Communication skill training in advance care planning conversations  Care planning in all settings including POA

7. Beaumont Hospital Discharge Guidelines For Patients Returning To Nursing Homes For Supportive -Comfort Care ( Pilot Project) These are guidelines for the medical team based on the patients medical condition and wishes under the direction of the patient’s consultant doctor and should accompany patient when transferred.

9. Irish Centre of Social Gerontology O’Shea, Murphy et al “It was so gradual. You could see the difference. I had been on night duty for a week and I could see the difference coming in for the week. I just said to the girls I think you know that (name) won’t be with us for much longer. You could see there was just a difference coming on her.” (staff nurse) [I said] “you are actually very ill these days and maybe the time has come that you will have to leave this world that you have been living in but we all hope we will go to a brighter place. Would you like to go to that brighter place?” I remember she said: ‘Nurse I wouldn’t mind; I’ve lived a very good life.’ Many staff only discussed death and dying if the resident brought up the topic first and acknowledged that they were dying. Contacting families as death approached was a priority of care. Staff found it easier to talk to families about dying and death than to patients themselves. Most patients retained a strong capacity for living in the face of their physical frailty Many patients focussed on their home and family. The ethos of end-of-life care was to make people as happy and comfortable as possible, which generally was understood to mean not telling people that they were dying.