You are on page 1of 28

Julian Abel Consultant in Palliative Care Weston super Mare, UK

Title -

Overview - In 2008 the Department of Health published the National End of Life Strategy. This document was the start of a large initiative to improve end of life care for all patients across the whole of the United Kingdom. Participation in this project has been met enthusiastically from hospital teams, hospices, primary care teams, ambulance services and care homes. We will discuss the major themes of the National End of Life Strategy and how these have been implemented in North Somerset, a community of 200,000 people in the south west of England. We will look at how compassionate communities fit into this model.

End of Life Care Strategy: Development


Election manifesto commitment: May 2005

Our Health, Our Care, Our Say: January 2006


Ministerial announcement of strategy: June 2006 Broad consultation with stakeholders Advisory Board + 6 Working Groups (Care

Pathway; Commissioning; Measurement; Workforce; Care Homes; Analysis/Funding) Original intention had been to publish by December 2007 Linkage to Next Stage (Darzi) Review

End of Life Care: Problems and Concerns (1)


Lack of familiarity with death and lack of public

discussion Low priority given to EOLC by the NHS and social care Clinicians difficulty in identifying people who are approaching the end of life Clinicians difficulty in initiating discussions Inadequate assessment and care planning Poor coordination of care Suboptimal services in hospitals, care homes and the community

End of Life Care: Problems and Concerns (2)


Poor care in the last days of life Problems after death (e.g. verification and

certification of death; viewing facilities etc.) Inadequate involvement and support of carers Inadequate training and education Lack of robust measures of quality and effectiveness of care Inequalities in care Lack of dignity and respect provided to some people

End of Life Care: Emerging themes


1. Raising the public profile of end of life care
2. Strategic commissioning (PCTs and LAs) to give a 3. 4. 5. 6.

whole systems approach An end of life care pathway Workforce development Measurement Funding

The End of Life Care Pathway


The End of Life Care Pathway
Step 1 Discussions as end of life approaches Open, honest communication Identifying triggers for discussion Step 2 Assessment, care planning and review Agreed care plan and regular review of needs and preferences Assessing needs of carers Step 3 Coordination of care Strategic coordination Coordination of individual patient care Rapid response services Step 4 Delivery of high quality services High quality care provision in all settings Hospitals, community, care homes, hospices, community hospitals, prisons, secure hospitals and hostels Ambulance services Step 5 Care in the last days of life Identification of the dying phase Review of needs and preferences for place of death Support for both patient and carer Recognition of wishes regarding resuscitation and organ donation Step 6 Care after death Recognition that end of life care does not stop at the point of death. Timely verification and certification of death or referral to coroner Care and support of carer and family, including emotional and practical bereavement support

Support for carers and families

Information for patients and carers

Spiritual care services

Population of each Strategic Health Authority

South West Strategic Health Authority

SHA end of life


Since 2009 Meeting of commissioners and lead clinicians 4 times per year meetings Outline development plan for SHA Division of MPET money about 1 million per year Year 1,2009- 10 focus on advance care planning, EPCCS, nursing home end of life Year 2, 2010 - 11 focus on general practice and use of end of life tools Year 3, 2011 12 focus on acute hospital

Changes in place of death South West Strategic Health Authority


Place of death SW residents 2007/08 - 2010/11
50 45
Proportion (%) dying in place

40 35 30 25 20 15 10 5 0
Hopital SW Acute Hospital Other Own Residence Nursing Homes Residential Homes Hospice Elsewhere

Place of death 07/08 08/09 09/10 10/11

End of Life Care North Somerset


2 major initiatives Development of advance care planning documentation Development of electronic palliative care coordination system

Advance Care Planning


Advanced wishes
Appointing someone to make decisions for you in the

future Putting your affairs in order Making a will Writing an advance decision http://www.westonhospicecare.org.uk/wiki/?page=adva nce_planning

Core Information
Main diagnosis Co-existing disease, complications or details Is patient aware of above? RESUSCITATION STATUS Has a DNAR/Planning Ahead form been completed? Patient lives alone?
Does patient have an informal carer? Does the patient have professional care? Just in case box completed & in pt house/hospice? Syringe driver available with patient? End of life care pathway in use? (eg, LCP) Primary contact Access details

Patient wishes for end of life care


Consent based model consent to share information

with appropriate health care professionals. Present on Planning Ahead and Register Place where wishes can be stored. Results and outcomes from Planning Ahead discussions Flexible up to date and can be changed Backed up by paperwork

EPCCS - Visible to the broader health community


GP surgeries
Out of hours services Ambulance service

A and E department
Hospital teams, including specialist nurses Hospice Community matrons and district nurses

All can see 24 hours per day up to date patient choices about end of life care

Use in GP surgeries
Palliative care meetings meetings at which patients

who have end of life needs can be discussed Does patient and carer have the right equipment for care, is there adequate support. Has there been a discussion about place of care and choices Review of what went well and what needs improving after the patient has died Not dependant on GPs making the decision to put patients on the register

EPCCS - Communication between health care professionals


Hospital and community teams see the same

information Uses the expertise of a variety of specialists The process of advance care planning can start in the hospital and get passed on to the community to continue Allows for discussion of patients who might not otherwise have been discussed

Percentage actual place of death in 6 month intervals from Jan 2009


40 35

30
25 20 15 home care home hospice hospital

10
5 0

Percentage patients without preferred place of death, 6 month intervals from Jan 09 with hospital deaths
70 60

50

40

hospital
30 no ppd

20

10

0 1 2 3 4 5

Actual place of death with and without ppd


45 40 35 30 25

No ppd
20 15 10 5 0

ppd

home

care home hospice

hospital

Choice of preferred place of death


60 50

40

30

20

10

home

care home

hospice

hospital

Percentage who died in hospital according to ppd choice


120

100

80

60

40

20

home

care home

hospice

hospital

Percentage actual place of death from cancer


35 30

25

20

15

10

home

care home

hospice

hospital

Compassionate Community Networks


Inspired by public health approach in Australia a nd

Kerala Focus on improving community resource returning end of life care back into communities Palliative care support to develop networks of family, friends and neighbours Development of neighbourhood networks of people who have supported someone who has died.

Compassionate community networks


Completion of advance care planning on average 3

months before patient dies Appropriate opportunity to start thinking about how care at home can take place Considerable challenges to current culture of communities in the modern day. Research grant application made in combination with Professor Tony Walter, Centre for Death and Society, University of Bath Application made for a Big Lottery grant through first phase

You might also like