1. Facilitating preferred priorities in end of life care
Jane Montgomery – Bangor University.
Catherine Jarvis – Plas Bod LLwyd, Care home.
Pauline Whilding – North Wales NHS Trust.

2. Impetus for this project:
An integrated team meeting project highlighted that:
Many residents who required end of life care in the residential care home setting were being admitted to the acute sector unnecessarily.
Wrexham South locality began an integrated teams project, which involved regular multidisciplinary team meeting to ensure continuity of care for people with complex health needs living in the locality.

3. Is admission to the acute sector at the end of life problematic?

4. It can be, for the following reasons:
Many individuals want to spend their last days in a familiar environment surrounded by people they know and trust (National Audit Office 2008).
Individuals often find themselves surrounded by strangers, in busy, often noisy environments.

5. It can be, for the following reasons:
Acute sector is organised to provide scheduled care.
Torjesen (2008) suggests that patients may experience care that is far from ideal.

6. What do people want?
If given the choice, most people would choose to die in their own homes, surrounded by people they know (National Audit Office 2008).
Individuals in residential care, view the care home as their home.

7. Why are people admitted to the acute sector?
Pressure / expectations from relatives?
Uncertainty of carers?
Lack of continuity of care from health care providers? (NAO 2008)
Lack of knowledge / information regarding the individuals preferences? (NAO 2008)
NAO (2008) unnecessary hospital admissions can be due to lack of timely access to advice, medication and other services in the community, and lack of information recording and sharing across agencies delivering care.
NAO – end of life care report, 26th November 2008, also found that many people receive inappropriate care because their wishes are not known or not recognised, eg. Do not attempt resuscitation orders.

8. What are we doing to facilitate choice?
Who are we?
We are a group of professionals who include, General Practitioners (Dr. Phil Davies; Dr. Rhys Davies), District Nurses (Pauline Whilding; Lisa Jones-Tattum; Natalie Jenkins-Jones), Social Worker (Andy Ecclestone), Care Home Manager (Catherine Jarvis), End of Life Nurse (Theresa Richards) & Higher Education staff (Jane Montgomery).

9. The PDSA model.
The project team decided to utilise the Plan, Do, Study, Act (PDSA) model for this intervention.

10. Plan:
Using multiple method data collection techniques the views of all stake holders involved will be sought.
These will include, care home residents, formal carers, general practitioners, district nurses, social workers and out of hours services.

11. Do:
Care home staff have been accepted onto the first wave of formal carer training offered as part of the GSF framework in England.
G.P.’s, District nurses and care home staff are using a preferred priorities documentation to elicit resident’s views.

12. Do:
District nurses and care home staff have designed and are operating an alert system, to identify residents who may require end of life care.
All team members meet regularly to discuss progress and debate any issues that arise.

13. Study: Analysis of the data collected will begin in spring 2010.
Patient journey data will be collated.
Carer’s attending GSF training will evaluate their acquired knowledge and skills.
Admissions to acute sector will be monitored.
G.P. call outs will also be monitored.

14. Act:
If the project is successful, the model can be adopted for all care homes within the locality.
Information would therefore be disseminated to all relevant stake holders.
Publishing results will provide an opportunity to widen the dissemination of this project.

15. Any questions/