1. Palliative Care- Hospital/ Community
End of Life care Initiatives
Right Care
Dr R Gaekwad

2. End of life care initiatives-overview
July 2008, the Department of Health published “The End of Life Care Strategy”, the first such strategy in the UK.
The aim of the strategy is to improve the provision of care for all adults approaching the end of their life, including support for their families and carers.
the implementation of this strategy would reduce inappropriate admissions to hospital, and enable more people approaching the end of their life to have access to high quality specialist palliative care, be able to live, be cared for and die in the place of their choice.

3. Gold Standards Framework, Liverpool Care Pathway for the Dying, and
Preferred Place of Care tools.
commitment to raising the standards of care for this special group of patients. It recognises that many patients wish to be cared for in their preferred place of choice, which may be their own home. It also pays particular attention to the support for informal carers, and to the provision of education and support for professionals to deliver a consistent and high standard of care.

4. Preferred Priorities for Care
Preferred Priorities for Care (PPC; formerly known as Preferred Place of Care) is an Advance Care Plan (ACP), in which individuals can write down their preferences and priorities for care at the end of life in order to help prepare for the future.
It is never too early to start a PPC plan particularly for residents in care homes, which for many is their permanent and final place of residence. The PPC provides an opportunity for care home residents and staff to work together to develop Advance Care Plans in accordance with the new Mental Capacity Act.
Residents can initiate the PPC at any time and this will help staff follow their wishes and act as an advocate if the resident loses capacity towards the end of their life.

5. Principles of GSF- 3 steps
1.Identify
Patients who may be in the last year of life & identify their stage
Use of the ‘surprise’ question, use of Prognostic Indicator Guidance,
Needs Based Coding
2.Assess
Current & future clinical needs & personal needs
Use of assessment tools, Advance Care Planning etc
3.Plan
Develop an action plan of care
Use 7 Cs key tasks, Needs Support Matrix, passport information etc

6. End of Life Care in Numbers
1% of the population dies each year
17% increase in deaths from 2012
40% of deaths in hospital could have occurred elsewhere
60% people do not die where they choose
75% deaths are from non-cancer conditions
85% of deaths occur in people over 65
£19,000 non cancer, £14,000 cancer average cost/patient in final year of life
2.5 million generalist workforce 5,500 palliative care specialists

7. GSF works- improving end of life care
Attitude, Approach and Awareness
Increasing confidence of staff about discussing end of life care
Increasing openness and confidence of staff
Patterns and Processes
Improved coordination and team working
Improving practical systems of care
Outcomes for Patients and Carers
Fewer hospital admissions and deaths, more dying where theychoose with considerable cost savings to NHS
More advance care planning discussions

8. Liverpool Care Pathway
The Liverpool Care Pathway (LCP) was developed between the Royal Liverpool hospital and the city's Marie Curie hospice in the late 1990s. The pathway was developed to try to provide the same level of nursing expertise at the end of life as during other treatments, regardless of the patients' chosen environment.
The pathway aims to guide members of the multidisciplinary team in matters relating to continuing medical treatment, discontinuation of treatment and comfort measures during the last days.

9. LCP RECOGNISE THAT DEATH IS APPROACHING
Studies have found that dying patients will manifest some or all of the following:
• Profound weakness - usually bedbound
• Drowsy or reduced cognition - semi-comatose
• Diminished intake of food and fluids - only able to take sips of fluid
• Difficulty in swallowing medication - no longer able to take tablets

10. LCP-Treatment of symptoms.
Discontinue any medication which is not essential
Prescribe medication necessary to control current distressing symptoms
All patients who are dying would benefit from having subcutaneous medication prescribed in case distressing symptoms develop
All medication needs should be reviewed every 24hrs
If two or more doses of prn medication have been required, then consider the use of a syringe driver for continuous subcutaneous infusion (CSI)

11. LCP The most frequently reported symptoms are:-
• Pain (Morphine, Diamorphine, MST, Fentanyl)
• Nausea / Vomiting (cyclizine, haloperidol,
metoclopramide, levomepromazine)
• Agitation / Restlessness(Midazolam)
• Excessive secretions / Noisy breathing (Hyoscine butylbromide)

12. RightCare
RightCare is a scheme which was designed by Derbyshire Health United (DHU) clinicians to ensure that seamless patient care takes place out of hours, when General Practitioner (GP) practices are closed.
RightCare is designed for patients with long term conditions and complex healthcare needs, including end of life patients.
The scheme helps to prevent unnecessary admissions to hospital and attendance at Accident and Emergency (A&E), lower patient anxiety, provides reassurance and allows patients to access the most appropriate heal

13. RightCare-suitability
The service is suitable for people with complex health problems and long term conditions-
Chronic Obstructive Pulmonary Disease (COPD),
those requiring palliative care,
frequent users of Accident and Emergency (A&E) and 999,
some people with Mental Health Conditions and Learning Difficulties

14. Right Care
devised with the patient by their own GP or other health care professional e.g. District Nurse, Community Matron, etc. and then shared with DHU, by secure
valid for up to 6 months
DHU currently share the information with NHS Direct, East Midlands Ambulance Service, Royal Derby Hospitals and Chesterfield Royal Hospital
Patients will have the dedicated RightCare Number which is shown on the RightCare Plan which will put them in contact with DHU directly.