1. Making Health Care Decisions End of Life Care
Dr Tony Jones
Board Member

2. Commissioning – a process of providing optimal services AND reducing unnecessary waste

4. Place of Death

6. The UK Leads the World in Quality of Death

8. Some Stats around Death, Dying and Hospitals
When surveyed approximately 65% of people would prefer to die in their own home 1
In West Kent 53% die in Hospital 2
(National Average – 57%)
At any one time about 25% of inpatients in acute hospitals are in their last year of life
On average people are admitted to hospital three times and spend nearly a month of the last year of their life in hospital
(1) National Audit Office
(2) EoLCIN

9. End of Life Process Nursing home Own home Residential home Hospital
Death
3 x

10. End Of Life Care for all Diseases
NEUROLOGICAL CONDITIONS
COMPLEX FRAIL ELDERLY
EOLC
CANCER
DEMENTIA
LONG TERM CONDITIONS

11. Illustration of Changing Functional Level over Last Year or so of Life
Illustration of Changing Functional Level over Last Year or so of Life. Slide courtesy of Whole Systems Partnership

13. The Down Side of Admission
Risk – 25% of patients are likely to sustain harm (New England Journal Med 2010)
The nature of a hospital environment
Dementia patients rate of cognitive decline increases 2 to 3 fold irrespective of length of stay
Cognitively impaired patients spend 2-3 weeks longer on average than non-impaired individuals
Patient preference to remain at home
Pressure from relatives and other professionals
Once admitted, decisions about long term care needs are not made in the optimum environment

14. Why do Patients end up in Hospital?
Clinician decision that the patient and/or their carers cannot manage at home
Busy clinician is managing a caseload and not just an individual patient
The right service response cannot be identified quickly
End of life preferences have not been discussed with the patient previously so wishes cannot be considered
Patient needs nursing care – which could be provided in community if identified earlier
Overall, a failure to identify the dying patient and to establish patient preferences

15. Where in the process might change occur?
Patient
at home
General practice
Out of hours
Home
Ambulance
service
A&E
In-patient
NHS Direct
We tend to think of the typical scenario as patient calls practice who may or may not visit but onward referral results. This of course is only one sequence of events that can lead to A&E attendance & possible admission. Each of the lines on this rather complex looking diagram is a point for potential action. Analysis of each of these pathways may yield ideas for potential change where alternative pathways of care can be envisaged
Community
care
Supervised care
homes
Where in the process
might change occur?
Public places

16. Possible Interventions 1. Risk Predictive Software

17. Identifying Patient Decline
For any individual the risk of admission is dynamic.
The rate of change in risk will vary from one individual to another.
Top 1%
Top 5%
Top 30%

18. The white arrows represent what is happening to the admission risk for individuals over a given time.
While for the majority the risk alters little over any given time period, for some the risks are escalating rapidly
Top 1%.
Top 5%
Top 40%
The risk is static for this individual

19. Possible Solutions 2. The Transition to End of Life Care

20. So what should the Model of Care look like?
Dementia
Physical OA
CKD
Psychologica l
COPD
Social
LVF
Spiritual
Disease management
Symptom Management

21. Possible Solutions 3. Advanced Care Planning

26. Possible Solutions 4. DNAR Status

28. First, do no Harm Hippocratic Oath
Prolong life or alleviate suffering?

29. What still needs to be done?
Better understanding of end of life care
Much greater use of Care Planning
Investment in community services including hospices
Systematic education of all professionals
More open discussion and engagement with patients and public about end of life care

30. What still needs to be done?
Table discussion:
What needs to happen/change to improve the person’s experience at the end of life?