1. End of Life Care At the West Suffolk Hospital
Title slide
Sam Hobson
Dr Rosemary Wade
END OF LIFE CARE PATHWAY

2. End of Life Care National Strategy, July 2008
Builds on NICE Supportive and Palliative Care Guidance 2003
Drivers for change
Patients want to die at home and not in hospital
We can not afford to have patients in hospital who don’t need or want to be here

3. More patients dying at home
How do we make this happen?
Identify early – well before ‘last days’
Fully inform patients and their families
Advanced care planning
Communicate patients preferences and wishes to primary care team

4. Which patients ?
Patients who are likely to be in their last year of life
Either know on admission (GP - GSF) or diagnosed during admission
Likely to have
Advanced cancer
Advanced heart, renal, respiratory failure
Advanced neurological conditions
Multiple co morbidity (frail elderly)
Explain GSF 4

5. GPs now use, GSF – Gold Standard Framework
Register of patients in last 6-12 months
All GP practices – QOF points
MDT meeting every 6-8 weeks
Patients’ needs discussed and care planned
Therefore inform GPs and refer to community nurses

6. WSH End of Life Care Pathway
Identify
Assess
Address
Communicate

7. Identify Assess Address Communicate
Patients who are likely to be in their last year of life
Either
Known on admission (GP GSF)
Diagnosed during admission
HISS – End of Life Care Alert - EOLC
EPRO – End of Life Care alert
HISS for ward clerks
EPRO for clinicians E 7

8. Identify Assess Address Communicate
On and during admission a full medical, nursing and occupational therapy assessment involving patients family and carers.
Social and occupational needs
Psychological well-being
Spiritual well-being and life goals
Often admission process sufficient

9. Identify Assess Address Communicate
Consider physical, social, psychological, spiritual and information needs.
Make clinical decisions appropriate for prognosis.
Give patient (and family) the information they need to take a full part in deciding their priorities for their care
Consider referral to:
In hospital - palliative care team, chaplaincy team, AHPs, specialist discharge planning etc
On discharge – Specialist palliative care providers, social services, carer support, community AHPs etc
Identify Assess Address Communicate

10. Identify Assess Address Communicate
To primary care on discharge
EPRO discharge letter, all letters
To family and friends if dying
Care of the Dying Pathway LCP
Into bereavement

11. Identify Assess Address Communicate
On discharge always send
EPRO End of Life Care discharge letter - A detailed discharge summary including information on patient’s diagnosis, prognosis, understanding of condition and preferences for care.
Single point of access referral to District Nurses for palliative care assessment

12. Care of the Dying LCP Vs 12
Integrated care pathway used at the bed side to document care given to patients in their last hours and days of life. 
Version 12 – to address concerns regarding nutrition and hydration and regular review – contains information leaflet for patients/relatives

13. End of Life Care Intranet pages
New site
Main pages
Pathway, Identify, Assess, Address, Communication
Additional pages
Care after death, WSH palliative care team, Community specialist palliative care, Resources/Links page

14. End of Life Care Intranet pages
Useful paperwork
To print off and use
Discharge in last weeks checklist
Rapid discharge home to die
LCP
Preferred priorities of care document

15. Training programme Sam Hobson – End of Life care PND
Roll out over next year
LCP Vs12 and End of Life Care to each ward
Governance meetings
Targeted groups

16. West Suffolk Hospital End of Life Care Strategy
To provide high quality care in accordance with patients wishes
To enhance communication and co-ordination
With challenge of
Patients with months, weeks, days and hours to live
Hospital wide – Patients in many settings, together with a range of appropriate medical and surgical care

17. Main messages - Doctors
Identify patients
Make clinical decisions appropriate to prognosis
Keep patients well informed (and their families) and support patients with their decisions
Make plans on discharge
Communicate with GPs on discharge and outpatient letters

18. Questions ???