1. An audit of end of life care MARK SHIPLEY

3. DOH End of life care strategy: quality markers and measures for end of life care http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalasset s/documents/digitalasset/dh_101684.pdf

4.  1) 100% of patients who die with lung cancer should have a standardised approach to end of life care, (for example, the Liverpool care pathway) including documentation of resuscitation decisions. DOH End of life care strategy: quality markers and measures for end of life care http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalasset s/documents/digitalasset/dh_101684.pdf

6.  Symptoms in last 48hrs lung cancer ◦ Pain 85% ◦ Anxiety 71% ◦ Dyspnoea 54% ◦ Cough 24% ◦ Nausea 21%

7.  In 100% of patients there should be prescription of symptom controlling drugs via appropriate route at appropriate dose.  2a) Opiate analgesia  2b) Antiemetic  2c) Antisecretory  2d) Benzodiazapine for anxiety Ellershaw John and Ward Chris, (2003) 'Care of the dying patient: the last hours or days of life.' BMJ, 326: pp30-34. The Liverpool Care Pathway. http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/

9.  3) In 100% of patients, if deemed to be in the dying phase then this should be communicated to the patient, and if appropriate, to the relatives (including resuscitation decisions.) Ellershaw John and Ward Chris, (2003) 'Care of the dying patient: the last hours or days of life.' BMJ, 326: pp30-34.

10.  October 2008 – September2009 at FRH  Cases identified by Clinical Coding  35 Cases with Lung Cancer as cause of death  1 case excluded as died at QEH  Notes obtained for 33 cases and were reviewed by MDS  Cause of death confirmed on Death Certificates

12.  30 Patients DNR ◦ 22 Consultant decision ◦ 7 SPR decision ◦ 1 SHO decision

13. 9 24

14.  9/30 Patients with DNR decisions who died of lung cancer had a standardised approach to end of life care  1 patient for resususcitation as died post stenting  1 Patient deteriorated following sudden unexplained deterioration  1Patient no DNR ? Omission

18.  Opiates given in 18 patients  Indication documented in 6 patients  In all patients where indication was documented – opiates were given

19.  Prescribed in 24 patients - Given in 21  Indication in 6 (4 given) 2b)Benzodiazepines for Anxiety

20. Anti-emetics given In 6 patients Indication in 4 ( Given in 50%) 2c) Antiemetics

21.  Hyoscine 400mcg s/c prescribed in 12/33  Indication documented in 1  Given in 5 patients 2d) Antisecretion

22.  Symptoms in last 48hrs lung cancer ◦ Pain 85% ◦ Anxiety 71% ◦ Dyspnoea 54% ◦ Cough 24% ◦ Nausea 21%

23.  Symptoms in last 48hrs lung cancer ◦ Pain 85%  Appropriate Analgesia 66% ◦ Anxiety 71%  Appropriate Antianxiety 68 ◦ Dyspnoea 54%  indication documentation? ◦ Cough 24%  Appropriate Antisecretory 15% ◦ Nausea 21%  Appropriate Antiemetic 18%

25.  End of life discussed with patient in 13/31 ◦ 1patient admitted unconscious ◦ 1patient deteriorated after falling causing LOC  Discussions with family 26/33

26.  Despite patients with lung cancer being identified as approaching end of life (By DNR) a standardised approach to end of life care is only used in 24%  Anticipatory prescribing is variable, indications are rarely documented and use of drugs is low ◦ Increasing indications may increase drug use  End of life is often not discussed with patients ◦ Discussions are twice as likely to occur with relatives