Best Practice in End of Life Care: Gold Standards Framework in Community Hospitals Programme Jo Smith - End of Life Programme Facilitator Ally Hardman – Locality Director & End of Life Care Lead

Aims of Gold Standards Framework in Community Hospitals Quality of care – to improve the quality of care provided for all patients approaching the end of life and improving their experience of care Coordination – to improve the coordination and collaboration of care within and between teams and across boundaries to ensure seamless care through improved organizational change. Outcomes – to improve patient outcomes, reduce acute hospitalization in the final stages of life and enable more to live well and die well in their preferred place of care.

Accreditation Process There are 4 parts to the GSF Accreditation Process: Outcome measures –summary of key outcome ratios – evidence of attainment of standards in key areas Audit Patient – After death analysis (5 deaths + 5 discharges) Staff – confidence & competency Organisational – attainment of key changes Portfolio of evidence – demonstrating attainment of the 5 standards plus patient case study & evidence of patient / carer feedback Assessment – 3 hour ward assessment visit from the national GSF assessment team

The Five GSF Gold Standards Right people – identification of patients nearing the end of life Right care – assessing their needs: clinical & personal Right place – planning coordinated cross boundary care Right time – planning care in the final days Every time – embedding consistent good practice and identifying areas to improve further

Right people – identifying the right patients Are we identifying the right patients & recognizing them early enough? Identify – on admission, identify whether the patient may be in the final year of life Code – use needs based coding and plan pro-active care with core care plan (needs support matrices) to give right care at right time Discuss – at regular multi-disciplinary team meetings the patients progress and pro-active care for the appropriate GSF code. Review regularly, recode as needed and review weekly as a minimum

GSF - Core Care Plans To give pro-active care, ensuring that appropriate care is being co-ordinated to meet the needs of the patient To give the patient the opportunity to discuss their wishes and preferences To ensure effective communication & collaboration across care settings takes place aligned with the patient’s needs

Right Care – assessing their needs clinical & personal Do we really know the patients and carer’s needs, wishes and preferences for care towards the end of their life? Assess clinical needs – clinical assessment using holistic approach and referral as needed to appropriate specialist services Assess personal needs – Advance Care Planning discussions: offer ACP discussion: (as capacity allows, best interests always considered) Initial introductory conversation and information leaflet Discussion of resuscitation status, preferred place of care and proxy spokesperson, LPA Full ACP discussion initiated and recorded Assess carer’s needs: informal carers and family are offered an assessment and are signposted and given appropriate support

Advance Care Planning Umbrella term for the voluntary process of planning ahead for possible healthcare decisions Enables communication of wishes, views and preferences Usually in the context of an anticipated deterioration in the individual’s condition and/or changes to capacity

The Treatment Escalation Plan (TEP) and Resuscitation Decision Record Documentation of plan of care for patients and whether they are for or not for cardiopulmonary resuscitation Focus around the process / discussions with patients / families / carers Adoption of one form across all of Cornwall's health community ensures continuity of care approach

Right Place – planning coordinated cross boundary care Living Well: are we planning across boundaries? Plan community support and care to reduce avoidable crises and readmissions Communicate with receiving healthcare team / GP the needs based code and recommended actions and progress of advance care planning Discharge planning – rapid discharge / fast track with appropriate follow up and referral in the community.

Right Time – planning care in the final days Dying Well: are we enabling care aligned to patient preferences in the final days? Care in the final days using five priorities of care guidance – individual end of life care plan Anticipatory prescribing – Cornwall anticipatory prescribing guidance Nominated clinician Care after death - including providing support and understanding to the deceased’s family and significant others throughout all stages.

Individual End of Life Care Plans Sensitive communication with the dying patient and those identified as important to them Support of family members and those identified as important to the dying patient Symptom control Food and drink Spiritual and religious care

Every time – embedding consistent good practice How will we sustain and build on these improvements to ensure we provide consistent high quality care for everyone of our patients nearing the end of life? compassionate care with dignity and respect for all patients / families regular audit and review weekly GSF key ratio outcomes staff training & education annual appraisal submission to the GSF national team

How do our patients benefit? Physical symptoms are anticipated and reduced where possible, before they cause problems They feel they have some choice and control and that choices around preferred place of care are discussed and recorded They feel supported and informed and that potential problems are anticipated and reduced. This includes from admission right up to discharge. Their family or carers feel enabled, informed and involved in their care and are supported as much as possible.

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