1. E ND OF L IFE C ARE T RUST L EVEL 2 P RIORITY A UDIT ‘5 Priorities of Care’ R Newman Oct 2015 (prelim report)

2. T HE 5 P RIORITIES OF C ARE AT END OF L IFE Background The 5 Priorities: Recognise Communicate Involve Support Plan and Do Audit proforma based around the details backing these criteria

3. M ETHODS Numbers: 132 consecutive deaths 29/03/2015 to 30/04/2015 102 ‘expected’ deaths (defined as at least 4 hours from recognition of dying to death of patient) Percentage ‘expected deaths’ = 102/132 = 77% If remove ED / Resus deaths = 102/117 = 87% Reviewers: Primary reviewer RN = 92 Primary reviewer ‘other doctor’ = 40 (33/40 of those underwent secondary review and revision by RN)

4. O THER ‘ DEMOGRAPHIC ’ INFORMATION Gender Expected Death: Male = 65%, Female = 35% Unexpected Death: Male = 53%, Female = 47% Age Range Expected: 52-95, average 79 Unexpected: 54-95, average 81 43% of expected deaths on 4 Wards (MAU 1 and 2, Escalation Ward, Wellington) 56% if added in Critical Care and Phoenix Only 13/102 expected deaths on ‘surgical wards’

6. R ESULTS –1 Recognition of dying within 48 hours of death in 42% patients Majority (78%) patients lacked capacity or capacity not recorded at time dying recognised Formal Capacity Assessment carried out in 18% (of those deemed to lack capacity / no capacity recorded) Lasting Power of Attorney recorded as present or absent in 12%

7. R ESULTS – 2 D/W patient with capacity = 59% D/W family / important other(s) of patient with capacity = 92% D/W patient without capacity ‘to limit of their capacity’ = 2% D/W family / important other(s) of patient without capacity = 94% Documented identification (to patient / family / important other) of: Consultant / Dr in Charge = 35% Nurse in Charge = 5%

8. R ESULTS – 3 Ceiling of Care Set = 98% (usually Consultant Ward Round) – See later re MDT comunication Wishes recorded Patient / LPA holder: Preferred Place of Care 7% Hydration / Nutrition 7% Family views recorded: Preferred Place of Care 16% Hydration / Nutrition 10% Family visiting / overnight stay59%

9. R ESULTS – 4 Previous Advance Care Plan documented = 26% Preferred Place of Care at End of Life only = 2% Verbal Wishes only = 22% Resuscitation Decision = 16% (usually evidenced by Allow Natural Death form noted to already be in place in community)

10. R ESULTS – 5 Support and Individual Care Planning: Psychological Needs: Patient 34% Family 14% Social Needs: Patient48% Family12% Spiritual Care offered: Patient and/or family4%

11. R ESULTS – 6 Support and Individual Care Planning: Documentation of Plan of Care agreed: With Patient23% With Family87% Plan included withdrawal of treatment in 38% Symptom Assessment:72% By nurses 93% By doctors86% Using EOL symptom Observation Chart 7%

12. R ESULTS – 7 Symptoms Assessed : Medication Prescribed Pain88%81% Dyspnoea49%36% Distress/81%69% Agitation N&V14%68% RTS39%60% (Respiratory Tract Secretions)

13. R ESULTS – 8 Plan of Care Recorded for: Hydration80% (mainly via iv fluid chart) Nutrition28% (enteral or parenteral nutrition plan; dietitian or SALT review) Blood Tests43% Other Ix38% Treatments94% Observations70% (NB evidence NEWS score often continued despite at ceiling of care) Pressure Area Care67% Time set for Review of Plan of Care in 15%

14. A CTIONS AND P OTENTIAL I NFLUENCES 1 TEP introduced July 2015 (opportunity to identify patient in last year of life, capacity assessment, setting of ceiling of care, recording previous advance care plans) ‘My Name Is….’ initiated October 2015 – potential to influence knowledge of Consultant and Nurse in Charge of Care (but still need to DOCUMENT) Common Anticipatory Prescribing Guidance across providers / settings of care in Cornwall introduced March/April 2015; Education and Training via project post March 2015 – March 2016

15. A CTIONS AND P OTENTIAL I NFLUENCES 2 End of Life Care Symptom Observation Chart introduced across all wards RCHT from July 2015 (but lack of knowledge / availability on the ground still an issue) Plan of Care Documentation needs to be developed and introduction and mandatory use supported at a senior level Record of Communication Documentation needs to be developed and introduction and mandatory use supported at a senior level Plan to re-audit 10-20 deaths by end of year to gauge influence of TEP etc.

16. K EY M ESSAGES – MAY VARY WITH S PECIALTY - 1 Do not be afraid of recording someone as needing ‘end of life care’ – does not mandate withdrawal of treatment and does not therefore influence outcome. Enables coding (income) Need to think earlier in admission, and before patient loses capacity, re appropriate discussion of wishes, especially re preferred place of care, limits to treatment, and hydration and nutrition CAPACITY ASSESSMENT is important and opportunity to document on TEP not yet being used regularly – not just present or absent If lacking capacity need to routinely record if any Advance Care Plans (especially Advance Decision to Refuse Treatment, and existence of Lasting Power of Attorney for Health and Welfare) exist

17. K EY M ESSAGES – MAY VARY WITH S PECIALTY - 2 Documentation of discussion with patients is as, if not more, important than with family / important others – make sure junior docs recording Ward Rounds aware of this need, not just recording an Action Plan Make sure any ceiling of care discussions are informed to nursing staff INCLUDING when appropriate to stop NEWS scoring if not for any further escalation Remember that our duty of care extends to family members / important others re assessing emotional social and spiritual care needs (and signposting to sources of info / help)

18. K EY M ESSAGES – MAY VARY WITH S PECIALTY - 3 Pastoral Care are part of the healthcare team, and very experienced / well trained beyond providing ‘religious’ support. Use them or lose them? Document any agreed care plan (agreed with patient or family / important others) – include hydration, nutrition, observations, blood tests, other investigations, treatments (especially withdrawal and who discussed with) Assessment of symptoms and prescribing for symptom control could be improved – one quick win IS using the End of Life Symptom Observation Chart Could also routinely prescribe opioids prn ‘for pain and / or breathlessness’ in last few weeks of life

19. O PPORTUNITY FOR LISTENERS Questions Comments Thoughts NB: Note re resource: Consultant / Specialist time in performing audit, producing poster and presentation and meetings re actions – so far conservatively 91 hours Education sessions to share learning on top of this. Junior medical staff time supporting audit not quantified Clinical Effectiveness Co-ordinator time taken feeding in and compiling data not quantified. Funding / Time allocation : None