1. Addenbrooke’s Hospital Rosie Hospital Caring for Patients in their Last Days of Life Dr Douglas Maslin (ACF CMT1) and Dr Kate Kiln (CMT2) Supervisor: Dr Rosemary Wade (Palliative Care Consultant) Background The ‘National care of the dying audit for hospitals’ 1 identified a number of key areas that hospital teams should focus on to improve end of life care. Such areas include a) ‘documented recognition that [patients are] in the last hours or days of life; b) ‘medication prescribed “as required” for the five key symptoms which may develop at the end of life’; c) ‘pain control and other symptoms in dying patients should be assessed at least four hourly’; and d) a ‘documentation of discussions about spiritual needs’. Project Aims The aim was to analyse and improve the standard of end of life care at our local hospital. If standards are not met, this will enable the introduction of interventions to improve practice and therefore care of the dying patient. Changes Initial audit results showed that improvements were required in, for example, the prescription of as required medications; the documentation of patient comfort and symptoms; the documentation of mouth care; and the care of the patient after death. Plans were therefore made, with the aid of recent guidance 2,3, to create a dedicated ‘last days of life’ flowsheet. This encompasses the key physical, personal, psychological and spiritual issues to be considered in dying patients (Figure 2). The aims of the new flowsheet tool are to: - Provide a dedicated place to document observations and care needs of the dying patient - Prompt documentation of discussions regarding dying, DNACPR, nutrition and fluids - Prompt regular checks of mouth care, patient position and patient pain score - Prompt the prescription of end of life medications - Provide a place to document care after death/last offices The Difference Made and Relevance to Practice Fig 2: Example of part of the ‘Last Days of Life’ flowsheet Fig 1: Length of time prior to death that dying is documented – time in which we should switch to focus on the care of the dying initiatives “Learning To Make a Difference” References 1.National care of the dying audit for hospitals, England. Executive summary, May 2014. Royal College of Physicians. 2. Department of Health. End of life care strategy: promoting high quality care for all adults at the end of life. London: DH 2008. www.gov.uk/government/uploads/system/uploads/attachment_data/file/136431/End_of_life_strategy.pdf [Accessed 20 April 2015] 3. General Medical Council. Treatment and care towards the end of life: good practice in decision making – guidance for doctors. London: GMC, 2010. www.gmc-uk.org/static/documents/content/End_of_life.pdf [Accessed 20 April 2015] Next Steps While this tool has been successful in its implementation in some parts of the hospital, and does successfully address key issues to be considered in the dying patient; it is clear that further work is required to encourage its use: -Circulation and Presentation of these results -Palliative care team to recommend appropriate use of the flowsheet in management plans -Further education of ward managers, nursing staff and doctors of implementation of the flowsheet - 29 of 98 (29.5%) of dying patients had use of and documentation within the ‘last days of life’ flowsheet. - 90 of 98 (91.8%) of patients had documentation within their notes that they were in the last hours or days of life. - 86 of 98 (87.8%) of patients had active medical management stopped when clinically appropriate. - A ‘discharge as deceased’ letter was written in 68 of 120 (56.7%) cases.