Sharing Current Scottish Practice

This blog provides an opportunity for people to share examples of current Scottish palliative care practice that might be of interest to the palliative care community more widely. If you know of work underway that might be relevant for sharing on our website, please get in touch.

Poster Abstracts of the Month: October

The SPPC Annual Conference in 2018 featured 48 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on:

Tackling Fatigue; Take charge! Recharge!

Author(s)

Donna Bruce

St Andrew’s Hospice Occupational Therapist has provided fatigue management as part our services for a number of years. However, following repeated requests from healthcare professionals in the community we agreed to develop and pilot an education session for patients on self-management techniques for fatigue. The aim of the pilot was to provide patients with adequate knowledge, empowering them to manage their own symptoms thus allowing them ‘to longer healthier lives at home or in a homely setting’ (Scottish Government 20/20 vision, 2011)

The Session was developed and ran by our specialist Occupational Therapist and consists of a one-hour session which teaches the concept of energy conservation in managing fatigue and introduces self-management tools such as the energy battery and activity diaries.

35 patients completed evaluation forms and the results show that 100% of attendees reported that they had learned techniques which could help them manage their fatigue.

Comments included:

‘To prioritise, to stop and think, to realise certain tasks can wait.’

‘Session was excellent and at right pace. Provided a much better understanding of fatigue’

Following the pilot, the education sessions currently run once per month and are led by a Rehabilitation Support Worker.

The Coracle Project - Art and Bereavement Support

Author(s)

Suzie Stark

Art and Conversation - Painting a Grief Journey

People who had completed 1:1 bereavement support sessions at a hospice were invited to take part in an art-based group project. The Coracle Project consisted of six sessions facilitated by the chaplain. The group explored words and images that encapsulated aspects of a grief journey with which all participants identified.

The analogy of being at sea in a small craft was used by the chaplain in 1:1 bereavement support sessions and was familiar to most of the group. The artwork depicts three different stages of a grief journey, noting that progress is not linear and stages might be experienced many times. Words, colours and images were used to create ‘mood boards’ and from these three paintings were produced - the turmoil of raw grief, the sense of being lost in fog and the longed for, but often elusive, calmer waters.

The paintings have been exhibited and used as conversation starters to help others discuss their feelings of loss and bereavement, demonstrating how conversation and art in a safe group environment can be beneficial for those taking part as creators and leave a legacy for others struggling with their own losses.

The FLTTN (Forward Looking To The New) Project

Author(s)

Claire Coleman-Smith; Niki Ferguson; Janette McGarvey

Story of the FLTTN Project:

At the Prince and Princess of Wales hospice we have an inclusive approach to caring for everybody affected through life-limiting illness and we deliver our holistic compassionate care, for people at the most difficult times of their lives; for patients, family members, carers and friends. Our specialist (bereavement) Butterfly Service, funded by the Big Lottery, specifically looks after children, young people and their families.

As part of the development of the butterfly service and inspired by the upcoming move to our new home at Bellahouston park we have invited a working group of young people with connections to the Butterfly service to co-produce a transitional creative project (THE FLTTN PROJECT- Forward Looking to The New). The project aim is to provide a platform for children and young people (CYP) to voice their collective experiences and thoughts on the transition from the historic Georgian building on Carlton Place to the modern 21st century new build in Bellahouston Park. This will involve CYP exploring all areas of the arts (Visual art, Music, Digital (film, photography and animation) Creative writing and Performance) to produce content for an exhibition to be held in 2018 (Year of the Young person) in the new hospice.

The emphasis is not necessarily on each CYP telling their own personal story about their connection to the hospice but rather to explore broadly the theme of transition and change; individually and/ or as part of a small group. The CYP will consider marking endings and establishing new beginnings, linking the past to the future, and how the spirit of a place can transition and evolve into a new environment to form new memories.)

Timely identification and support for carers of people at the end of life through the Adult Carer Support Plan

Author(s)

Emma Carduff; Richard Meade; Susan Swan

Introduction:

The Carers (Scotland) Act (2016) places a duty on local authorities to prepare an Adult Carer Support Plan (ACSP) for any carer who requests one or is identified as such. From 2020, this will be assisted by a fast track process for carers of people in their last six months of life.

Aim:

To provide evidence on the supportive needs of carers to inform recommendations regarding the timescale for the creation of fast tracked ACSPs under the Carers (Scotland) Act (2016).

Methods:

The study triangulated data from a literature review, qualitative secondary analysis (n=19 interviews; 3 focus groups) and two primary focus groups with bereaved carers (n=11).

Results:

Themes included; barriers to and triggers for identification and needs including physical support, psychological support, respite, information, communication, co-ordination and competing demands. Additional themes were speed of decline and end of life care.

Conclusion:

Health and social care professionals need to take a radical, reactive move to presume that every patient has a carer and ensure they understand their entitlements. Carer identification is everyone’s responsibility and it should be the ambition of the Carer (Scotland) Act (2016) that this happens early in the illness trajectory. In so doing, rapid assessment and support can be initiated to help carers navigate and cope with an uncertain, often rapidly deteriorating illness trajectory.

Triggers for the Pharmacological Management of Delirium in Palliative Care

Author(s)

Catherine Fairfield; Anne Finucane; Juliet Spiller

Introduction:

Delirium is a serious neurocognitive disorder with a high prevalence in palliative care. There is a lack of evidence of benefit for pharmacological interventions such as antipsychotics.

Aims:

1) To determine the prevalence of delirium in a palliative care inpatient setting and how it is documented/described by staff. 2) To determine the extent delirium screening tools are used in its identification and how they are viewed by staff. 3) To determine the triggers for pharmacological intervention in managing delirium in palliative care.

Methods:

A case-note review of admissions to Marie Curie Hospice Edinburgh from 1st-17th August 2017 was performed as were small group interviews with hospice doctors and nurses.

Results:

21 patients were reviewed. 76% had documented symptoms of delirium and 62% were screened on admission. Its documentation/description was variable and the term itself was used infrequently. Midazolam was the most commonly used medication. Triggers for pharmacological intervention included failure of non-pharmacological measures, distress, agitation and risk of patient harm.

Conclusions:

The infrequent use of the term delirium suggests it may be under-recognised.

Triggers for pharmacological intervention are in-keeping with guidelines, however the level of understanding of delirium’s presentation varied between participants.

Use of Propofol in a Specialist Palliative Care Unit

Author(s)

H Crockett; C Ross

Purpose of audit:

Propofol is a fast-acting general anaesthetic agent. However, beneficial use of propofol in palliative care has also been reported, in refractory agitation. This has informed the practice of our specialist palliative care unit. The purpose of the audit was to monitor adherence to the unit’s propofol protocol.

Methodology:

A protocol for propofol use in refractory agitation was developed in 2011 in our specialist palliative unit. A proforma was used to document use over the next six years.

Results:

There were nine episodes (seven patients) of propofol use. The indications for use included refractory agitation, status epilepticus, and sedation for NIV removal. In non-seizure related episodes, a benzodiazepine and antipsychotic had been used prior to propofol, as a minimum. The propofol infusion was stopped when the patient died in seven episodes, and when symptoms had resolved in two episodes.

Conclusion:

Propofol use is well documented and has a valuable role in palliative care. A new proforma has been written to allow for more robust auditing of the use of propofol. Propofol has been used very infrequently, but the impression of the specialist staff is that is an invaluable tool for very difficult and refractory cases.

Views of Care - Delivering End of Life Care Now and Improving for the Future

Author(s)

Bridget Johnston; Elaine O’Donnell; Patricia O’Gorman; Claire O’Neill; Jackie Wright

Obtaining feedback on End of Life Care from dying people and their relatives is difficult. This pilot project tested the use of questionnaires to gather views on end of life care from relatives /friends in the acute setting.

Aim:

• Test the feasibility of collecting feedback using questionnaires

• Capture qualitative Views of Care

• Identify areas of good practice and areas for improvement

A sensitive questionnaire was issued to relatives in pilot sites when collecting the medical certificate of death. After 6- and 12-months questionnaires were issued to gather staff opinions of the project.

The feedback revealed that high quality End of Life Care is being delivered and that this is important to both relatives and staff. 32 questionnaires were received from bereaved families. Themes emerging included communication, compassion and emotional support. Areas for improvement were also identified.

Staff questionnaires captured valuable feedback both benefits and concerns were identified.

This project has been effective in obtaining valuable feedback from bereaved relatives. The results identify good practice and highlight areas for improvement.

More research is required to identify the optimal timing and method, such as using technology, for obtaining views of care at end of life from bereaved relatives.

What Matters at end of Life - Using Principles of End of Life Care in Clinical Practice

Author(s)

Morven Kellett; Lesley Murciano; Evelyn Paterson; Helen Upfold

This poster has translated the 4 principles of end of life care (ref: Caring for People in the last Hours and Days of Life, Scottish Government National Statement 2013) into more memorable language; Communicate, Collaborate and Co-ordinate, Care and Comfort, Compassion. It has been used to raise awareness of the principles of end of life care and as an educational tool - asking multidisciplinary staff to reflect on how their care delivery aligns with these principles and to identify areas where improvements could be made.

What matters to you?’ Staff perspectives on the identification and documentation of ‘What matters’ and the role of values-clarification in palliative care settings

Author(s)

Anne Finucane; Jack Irvine; Juliet Spiller

Introduction:

Values-clarification has an important role in palliative care for clinical staff and their patients. The question ‘What matters to me?’ forms part of the daily assessment of each patient at the Marie Curie Hospice Edinburgh.

Aims:

Explore staff perspectives on the role of understanding patient values and their interaction with clinical practice.

Methods:

A service evaluation investigating the practical application of ‘What matters to me?’ as a proxy question for values identification, using a retrospective case notes review and focus group discussion. Data was qualitatively analysed.

Results:

Doctors recorded ‘What matters to me?’ information most frequently (52%). Focus group results indicated widespread understanding of the importance of values to staff personally but revealed varying approaches to electronic documentation. Multidisciplinary team meeting electronic records were found to be less useful than intended. Quality of evidence of community documentation of ‘What matters’ being transitioned to the inpatient setting was, overall, positive. Core themes included family, being at home and general health.

Discussion:

Extensive agreement regarding the positive impact of using the ‘What matters to me?’ question to elicit patient values. Implications for hospice practice include clarifying electronic documentation practices, increased healthcare assistant access to electronic records and regularly updating nursing handover sheets.

Working Together Learning Together, Collaborative Working: Single Nurse Controlled Drug Administration

Author(s)

Irene Barclay; Kim Donaldson; Helen Keefe; Dorothy McArthur; Libby Milton; Dot Partington

Single Nurse-Controlled Drug Administration (SNCDA) was developed in response to registered nurse (RN) concerns that patient waiting times for controlled drugs (CDs) were excessive and the two-staff resource impacted other responsibilities.

SNCDA is used in various healthcare settings and although RNs may have initial anxieties there is no evidence to suggest it has any adverse effect on safety. Many feel it is safer.⁽¹⁾

A practice development approach was used to elicit the values and beliefs of IPU (Inpatient Unit) RNs surrounding SNCDA which informed policy, procedure, risk assessment and the programme of education. Roll out was gradual allowing confidence building in the process. Following the second successful cohort the clinical pharmacist, working across two hospices, recognised the potential in the second hospice and presented a proposal for collaborative working. Following scrutiny via the second hospice’s clinical governance structure, the two hospices entered into a joint working agreement.

Working in partnership has offered an opportunity to strengthen relationships and ensure quality and equity across both sites. Staff report feelings of autonomy, empowerment and of being more responsive to patient need.

⁽¹⁾ Taylor, V. Middleton-Green, L., Carding S. and Perkins P. 2016. Hospice nurse’s views on single nurse administration of controlled drugs.

Posted on October 28 2019 at 11:32

Poster Abstracts of the Month: September

The SPPC Annual Conference in 2018 featured 48 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on six of these:

Pressure Ulcer Prevention in Palliative care

Author(s)

Katherine Hynd, Libby Milton

‘Pressure ulcers impose a significant financial burden on health care systems and negatively affect quality of life’ (Moore and Cowman 2013).

Marie Curie (MC) recognised that pressure ulcer (PU) prevention/ management was an area where practice could be improved.

Approaches:

Leadership

• Creation of link nurse role

• Commitment by MC to support the development of link nurse

• Participation in national MC TV working group

Clinical

• Review of risk assessment and implementation of updated assessment tool

• Low threshold to reporting all PUs acquired in our care regardless of grade

• Ensuring most appropriate equipment in place

• Review and development of documentation

Educational

• Developed teaching package for RNs and HCAs

• All staff included in roll out of teaching – face to face sessions to allow space for group

discussions and individualised learning

• Developed materials to display on the wards

• Link nurse role to offer support and guidance in practice

Cultural shift

• Every PU acquired in our care investigated and RCA completed, with feedback to the team

• Raised profile of patients who are at risk in patient safety briefs

Outcomes:

• Incidence of PUs acquired in our care demonstrates sustained improvements, with 9 sequential

months data below previous average.

Raising Death Awareness in Thailand, the Case of Life Unlocking Card Game

Author(s)

Tanida Apichanakulchai; Deans Buchanan; Linda McSwiggan; Tharin Phenwan; Ekkapop Sittiwantana; Judith Sixsmith

Introduction:

Advance Care Planning (ACP) is an agreement of preferred care between patients, family, and the health care team should the patient become incapacitated. However, ACP uptake and awareness is still low in Thailand. The Life Unlocking Card Game is an intervention that aimed to use gamified element to raise ACP awareness. This study assessed the effectiveness of the Life Unlocking Card Game as a tool to raise death and ACP awareness in Thailand.

Methods:

A retrospective feasibility study using a convenient sampling method with Thais participants who are older than 18 years old. 27 card game sessions were held during January 2014 and December 2016 with 342 participants. We used data from an anonymised pre-game and post-game survey for participants' demographical data and evaluation feedback. Data was analysed using thematic analysis with investigator triangulation.

Results:

Three themes emerged; 1) Closeness of death, 2) Co-construction of the meaning of death, 3) the obligation and importance of ACP.

Discussion and conclusion:

The Life Unlocking Card Game is a useful tool to raise death and ACP awareness amongst Thais. Further study is recommended with other groups such as the patients, carers, and healthcare professionals.

ReSPECT - Find out what it means to me

Author(s)

Dr Sean Duignan; Dr Lynsey Fielden; Dr Jennifer McNeill

‘ReSPECT’ (Recommended Summary Plan for Emergency Care and Treatment) is a process which facilitates emergency and anticipatory care planning. All new admissions to an acute ageing and health receiving ward were screened between 10/5/18 and 10/6/18 for ReSPECT ‘triggers’. If trigger positive, retrospective assessment of escalation planning was conducted by reviewing whether there was a pre-existing KIS (Key Information Summary), ReSPECT form or consultant escalation plan on admission. These triggering patients were highlighted to the medical team in the patients notes as a prompt to consider a ReSPECT discussion with patients and families.

Since ReSPECT screening has started and ReSPECT documents have been completed for patients, there has been an increase in the number of documented emergency/ anticipatory care plans in the form of: KIS; admission escalation plans and ReSPECT forms. This reached a total of 100% of patients screening ‘positive for ReSPECT’ in the final week.

Scotland’s first pilot of the ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process

Author(s)

S Campbell; LA Fielden; D Lynch; K Petrie

Background:

Across Scotland, there is no universal process for recording emergency treatment discussions besides DNACPR decisions which have been associated with negative connotations. The ReSPECT process creates personalised recommendations for a person’s clinical care in a future emergency when they are unable to make/express choices. Resuscitation decisions are considered as part of an overall treatment plan. The aim of the pilot was to evaluate ReSPECT by obtaining feedback from patient, carers and staff.

Methodology:

A small pilot of ReSPECT was introduced in 4 key areas (acute care of the elderly ward, adult mental health, day hospice, 2 GP practices) from November 2017 to May 2018. We obtained feedback from patients/carers who had been through the process; public carers forum; staff who had utilised the ReSPECT process.

Results:

180 people experienced the ReSPECT process. Patient/ carer feedback was overwhelmingly positive with the vast majority describing the process as ‘excellent’ and the remaining ’good’. All felt that ‘what matters to you’ was considered and they were involved in the decision-making process. Similarly, the carers forum described the process as excellent or good. 94% of staff felt that ReSPECT involves the patient and/or family in decision making. 88% felt ReSPECT would help the individual/ team deliver the most appropriate care for patients. This feedback will be utilised to shape the roll out of ReSPECT across NHS Forth Valley to facilitate truly person-centred care in emergency/ anticipatory care planning.

Sharing the Learning at the Palliative Care in Prisons Conference

Author(s)

Gail Allan

Background:

The Scottish prison population is disproportionately drawn from the most deprived areas in Scotland and have an increasing ageing population. The nature of offending and longer prison sentences means there is an increasing number of prisoners who will be facing end of life in prison. In September 2018 the first Palliative Care in Scotland's Prisons Conference took place.

Aims:

The aims of the conference were to raise awareness about the need for a Supportive and Palliative Care approach in Prisons and share the current work that was taking place in Scotland's prisons.

Approach:

Invited speakers addressed the issues of why prisons should develop a supportive and palliative care approach. Both NHS and Prison Service staff shared the work they were undertaking in their prisons to address these issues.

Workshops allowed the audience to engage with the staff that works in prisons. They were asked to share what they have done to support palliative care in prisons and who they should connect with to support this work.

Results:

ÂŸ Increased stakeholder engagement with project

ÂŸ Development of Macmillan Palliative care in Prisons Community of Practice

Supportive and Palliative Care in HMP Glenochil

Author(s)

Gail Allan; Fiona Donnelly; Fiona McAinsh

Background:

The fastest growing population in Scotland’s prisons is males over 50. The prison health demographics sees the health age of most prisoners as being at least a decade older than the general public, with a shorter life expectancy. A recent report, Who cares? The Lived Experience of Older Prisoners in Scotland’s Prisons by HM Inspectorate of Prisons Scotland highlighted the case of ageing prisoners. It also discussed the challenges for the staff working in prisons in caring for this group.

Aims:

HMP Glenochil are taking a proactive approach in supporting the staff and people in their prison.

Methods:

ÂŸ Education

ÂŸ Use of Early identification tools

ÂŸ Improving multidisciplinary working

ÂŸ Improving communication systems.

Results:

ÂŸ Delivered Education sessions including Macmillan Foundations in Palliative Care Programme

ÂŸ Development of Palliative Care Champions

ÂŸ Development of Supportive and Palliative Care Meeting and Register

ÂŸ Development of Gold Standard Folder for Prison use.

Posted on September 26 2019 at 13:01

Poster Abstracts of the Month: August

The SPPC Annual Conference in 2018 featured 48 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on six of these:

Managing Long Term Conditions in the Community: A Specialist Palliative Care Community Services Approach

Author(s)

Veronica Turnbull

An ageing population is increasing the demand for multi-morbidity care, including palliative care. However, disparities exist in access to palliative care for patients with long term conditions.⁽¹⁾ In Scotland the majority of palliative care is provided by generalist health and social care teams, with support from specialist palliative care professionals.⁽²⁾ This work considers St Columba's Hospice Community Service developments that have improved access to specialist palliative care for people with long term conditions, and opportunities for next steps. Self-management, integrated working and education of generalist health and social care teams are presented considering challenges, opportunities and recommendations for practice.

References:

⁽¹⁾ Marie Curie (2015). Triggers for palliative care improving access to care for people with diseases other than cancer. Retrieved from https://www.mariecurie.org.uk/globalassets/media/documents/ policy/policy-publications/june-2015/triggers-for-palliative-care-full.report.pdf

⁽²⁾ Chest Heart and Stroke Scotland (2018) Scottish Non-Malignant Palliative Care Forum (SNMPCF)

Retrieved from: https://www.chss.org.uk/health-professionals/professional-forums-groups/scottish-non-malignant-palliative-care-forum-snmpcf

Multi-Disciplinary Palliative Care for Men Living with Duchenne: A Qualitative Interview Study

Author(s)

Dr Emma Carduff; Dr Sheonad Laidlaw

Background:

Duchenne Muscular Dystrophy (DMD) is an x-linked, ultra-rare neuromuscular condition affecting 1 in 3600-6000 live male births. Individuals live with an exceptional illness trajectory of prolonged dwindling, frailty and high symptom burden. A co-ordinated multidisciplinary team approach may increase the survival of those with DMD and improve their quality of life (QoL).

Aim:

To investigate QoL in adults with DMD living in the West of Scotland (WoS). Methods: The SEIQoL-DW tool was used to assess the five most important elements that contribute to an individual’s QoL – these were then used to guide qualitative interviews with 6 men in the WoS. A thematic analysis was undertaken.

Results:

Men living with DMD in the WoS described living good lives but feel “forgotten” due to perceived gaps in their care: poorly co-ordinated and infrequent health care; lack of multi-disciplinary team input and holistic care; and poor or no access to allied health care professionals, for example physiotherapy and psychological support.

Conclusions:

Numerous opportunities exist to introduce palliative care gently, as part of the MDT, early on and throughout the illness trajectory. Better co-ordinated multi-disciplinary care may be a solution allowing for an early introduction to palliative care and proactive advance care planning.

Palliative and End of Life Care: What do we know from Hospital, Hospice and Community data?

Author(s)

Aghimien Iyayi-Igbinovia; Andrew Mooney

The Information Services Division (ISD) presents a range of information to support the Scottish Governments Strategic Framework for Action on Palliative and End of life care. Information presented in this poster covers hospital, inpatient hospice and community activities to report on palliative and end of life care. This includes the annual end of life publication, place of death and end of life care pathways.

Palliative care for prisoners: a partnership approach

Author(s)

Dr Rachel Kemp; Libby Milton; Barbara Stevenson (Marie Curie Hospice, Edinburgh)

Gerry Michie; Angela Wotherspoon (HMP Edinburgh)

Background:

HMP Edinburgh has one of the highest populations of older, long term prisoners in Scotland. There are specific challenges to ensure high quality palliative and end of life care for this group. Barriers include:

• Identification of prisoners with palliative care needs

• Lack of 24/7 health care

• Timely access to medication

• Prison environment and regime

• Staff confidence and competence

• Serious sex offenders unlikely to be eligible for compassionate release.

Aim:

We have developed a partnership with our local prison, HMP Edinburgh, to transform the experience of palliative care for prisoners by:

1. Proactive identification of those with palliative care needs

2. Appropriate assessment and management plans

3. Planning to ensure palliative care needs can be safely and effectively met in the hospice or the prison

4. Support for staff

5. Addressing the barriers to out of hours health and social care support and access to medicines.

Approaches:

Initiatives focusing on the following three areas were developed:

• Clinical

• educational

• cultural shift.

Outcomes:

• Hospice staff attend prison palliative care meeting

• Prisoners with complex needs referred to specialist service

• Plans in development to access out of hours nursing care and medication

• Commitment to ongoing development work

• Hospice staff supportive and confident to look after prisoners

• Partnership with prison viewed by charity as an opportunity not a threat.

References:

Strategic Framework for Action on Palliative and End of Life Care. Scottish Government, 2015

Older Prisoners: learning from PPO investigations. Prison and Probation Ombudsman, 2017

Health and social care needs assessments of the older prison population. Public Health England, 2017

Palliative Care Guidelines in Practice – Impact on Patient Care

Author(s)

Charis Miller / Alison Winning

In order to assess the impact of the guidelines on patient care, a survey was circulated to palliative care networks and published on the guidelines website. The survey asked five questions to establish which guidelines are most used, how they are used in practice and what alternative sources of information practitioners use.

The poster will showcase key results from the survey and examples of how the guidelines have been used in practice to improve patient care.

Perceptions of palliative care community nurse specialists (CNS) of the feasibility and acceptability of introducing routine screening of delirium in the community palliative care setting

Author(s)

Anne Finucane; Tabitha Kanyui; Libby Milton

Background:

Delirium is a frequently misdiagnosed syndrome and palliative care community CNS are the best placed healthcare professionals to assess and recognize it by conducting routine delirium screening in the patients they care for. The 4AT is a brief tool that can be used to screen for delirium in any setting, though has been little evidence to date on its use in hospice settings.

Aim:

To explore CNS perceptions of the feasibility and acceptability of introducing routine screening of delirium in a community palliative care setting.

Method:

Semi-structured interviews with 12 community CNSs from a Scottish hospice.

Results:

Using the 4AT for routine screening of new patients referred to a community specialist palliative care team was feasible and acceptable to community nursing staff. Furthermore, staff perceived patients and families as mostly positive about its use. Overall CNS perceived it as useful in aiding early identification of delirium, though there was less consensus around when re-screening should occur.

Conclusion:

Further consideration on triggers for re-screening community patients is required, given the fluctuating nature of delirium, and the potential distress it causes.

Posted on August 14 2019 at 12:36

Poster Abstracts of the Month: June

The SPPC Annual Conference in 2018 featured 48 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on six of these:

Inspiring Leadership leading self; leading with others in a palliative care setting

Author(s)

Claire O’Neill, Jane Miller, Susan Jackson, Fiona Wylie.

Aims:

Pilot and evaluate a leadership programme for band 6 Palliative Care Clinical Nurse Specialist’s working within NHSGGC acute and hospices. The programme focussed on the leadership behaviours set out in the NHS Scotland Leadership Qualities Framework.

Methodology:

The programme aims included to build participants personal effectiveness, resilience and create a network of support, develop leadership behaviours consistent with an enabling culture and deliver a quality improvement project demonstrating impact on patient and families’ care experience. Participants attended master classes on:

• Myers Briggs and Working with Differences

• Quality Improvement Methodology

• Influencing skills

• Strategic landscape for Palliative Care.

They undertook 360 review with feedback sessions linking with PDPs, Action Learning Sets, shadowing opportunities and completed a work-based QI project.

The programme was evaluated using a combination of quantitative and qualitative data collection methods.

Results:

The evaluation data indicates that this was a very effective programme. The line manager / key person qualitative data supported the views of the participants by giving tangible examples of the impact of the programme at individual, patient, team and organisational levels.

Recommendations:

The outstandingly positive evaluation of the programme supports the view there is a need for this programme to continue.

Investigating the need for palliative care among people who are homeless in Scotland

Author(s)

Joy Rafferty

A scoping exercise assessed the need for palliative care among people who are homeless in Scotland. Published homelessness data estimated the number of homeless people in Scotland. Literature review examined morbidity and mortality, challenges of providing palliative care to homeless people and their views on palliative care.
There were 34,100 homelessness applications in Scotland in 2016/17 though the true number of homeless people is likely double this. The literature shows complex palliative care needs with homeless people having significantly worse symptoms at end of life than other populations. Challenges to providing palliative care described in the literature include uncertain prognostication, complex trauma, chaotic lifestyles, service design and delivery and few available options. In published research homeless people expressed fears of dying anonymously, alone, on the streets and not being found and of being forgotten after death. Self-determination was vital, with concerns admission would cause a loss of freedom and control. Psychosocial care, staff availability, continuity and developing trusting relationships were essential. The importance of staff reaching out was expressed.
We need to consider how palliative care services can be more accessible and responsive to the needs of people who are homeless in Scotland.

Kilbryde Hospice to Kirriemuir Nursery: See how our garden grows!

Author(s)

Karen Kilpatrick; Melissa Woodhouse

Background:
Kilbryde Hospice Day Services, providing a rehabilitative model of care, was keen to introduce therapeutic horticulture to promote independence and promote wellbeing. Equally, a local nursery wished to establish a link to the hospice. A joint project to promote an intergenerational partnership was established in April 2018 to establish and maintain the external gardens in the new hospice grounds. Epstein & Boisvert (2006) reported the benefits of an intergenerational space that is shared whilst Kaplan, (1995) acknowledges the use of natural environments to be beneficial in promoting wellbeing. This project endorses Scottish Government Health& Social Care Standards (2017) to encourage hospice staff to provide activities that patients can participate in either indoors or outdoors.
Aim:
To provide social and therapeutic horticulture to Kilbryde Hospice Day Services patients improving their wellbeing through active or passive gardening. Involving the nursery children allows a working relationship to develop, expanding their knowledge of plant life and develop their social skills within the hospice environment.
Method:
Nursery:
• Weekly visits by nursery children to hospice for 30 minutes
• No more than 8 children in a group at the one time
• Children accompanied by 2 or 3 staff members
• Kirriemuir staff fully responsible for the children on their visit
• Hi-visibility vests provided by nursery to be worn by children
• Children and patients to maintain 3 main garden areas; patio, front garden and rear garden.
Hospice:
• Therapeutic horticulture planned within Hospice Day Services 13-week programme
• Provision of one clinical support worker and 2 volunteers per session
• Patient choice to attend the session
• All levels of mobility catered for
• Fundraising Team at Kilbryde arranged for donation of plants and soil.
Results:
6 patients with regular horticulture participation
• IPOS scores decreased in feelings of anxiety and worry in 3 patients
• IPOS scores improved in feeling depressed in 3 patients
Children:
“I like going to help everyone at the hospice” HL
“I loved all the plants because some were coloured” JD
Kilbryde Patients:
“Kids make us laugh with what they say and do” AMH
“Both patients and children enjoy mixing. Long may it continue!” TH
Nursery Staff:
“Promotes the bond between adults and children working together” MW
“Children have developed a sense of responsibility” JA
Kilbryde Volunteers:
“Loved listening to kids asking patients about plants” ME
“Watching the children interested in the flowers and sharing tasks, they brightened up the patient’s day.” MI
Conclusion:
• Improved outcomes on measuring feelings of anxiety, worry, depression
• Apparent improvement in social isolation
• Introduction of therapeutic horticulture has now been embedded into Day Services 13-week
programme.
• A planned seasonal project has extended to throughout the year with periodic adjustments
• Exclusively positive feedback from all 4 sources
• Nursery visits have increased to twice a week as a result.
References:
Epstein,A.S. & Boisvert,C. (2006) Let's Do Something Together Journal of Intergenerational Relationships. 4 3 87-109
Kaplan S. (1995) The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology. 15(3):169-182.
Scottish Government (2017) Health & Social care Standards. My support, my life. Crown Copyright

Lessons learned from integration of IPOS into the Community: Building relationships and sharing learning and understanding between Specialist and Generalist Palliative Care Services

Author(s)

Neill Cree; Dr G Dunnet; Dr S McConnell; Dr J McKane; Janice Renfrew; Dr C Sime; Dr John Thompson; Dr Margaret Thompson

The aim of the project was to embed the use of the Integrated Palliative Outcome Scale (IPOS) within the Inverclyde Community Primary Care teams. IPOS is a validated and reliable tool used to identify unmet needs for people living with a life limiting illness. IPOS use within primary care is an innovative strategy. IPOS use in Specialist Palliative Care Services is well established.
We identified key barriers and challenges to collaborative inter-disciplinary working within Generalist and Specialist services. We acknowledged the different priorities in managing patients with life limiting illnesses and focused on innovative solutions to translate and integrate the use of IPOS into the Community.
We had to establish project momentum by supporting community staff. We developed case-based reflections, education and mentorship programmes to enable practices to embed IPOS development whilst supporting teams to develop clinical governance solutions to allow maximal impact of IPOS. We trained IPOS champions in the community to allow learning to be shared.
We identified key barriers and developed multifaceted solutions for the interaction and communication between Generalist and Specialist Palliative Care Services during integration of a new tool in an environment where Generalists have competing demands, specific to their specialty.

Lifetime in Pebbles

Author(s)

Shona Crain; Mairi-Ann Higgins; Ishbel Murdoch

The poster displays a creative project that tells the story of the growth of the Accord Hospice in Paisley where a large pebble mosaic has been hand painted by patients, families, volunteers, staff and local school children. The creation of the mosaic has involved the therapeutic benefits of art and is a reflection of the community the hospice is embedded in. It is installed in the gardens of the Accord Hospice.

Making a Difference – The Provision of Palliative and End of Life Care within a Community Hospital

Author(s)

Lynne Hoffin; Linda Kerr; James Mack; Dr Jillian Nicoll; Dr Kathleen Sherry; Morag Thomson; Karen Wilson

Patients in their last year of life use 30% of all acute hospital bed days. Evidence shows that over 50% of Scotland’s annual deaths take place in hospital. About 50% of NHS complaints relate to end of life care.

Community hospitals such as the Biggart Hospital play an important role in the provision of healthcare. They are at the forefront of shifting the balance of care from acute services into the community and they are ideally placed to develop a range of services focussing on the provision of palliative and end of life care.

MacMillan ward is a 23 bedded which specialises in palliative, end of life and Hospital Based Complex Continuing Care for patients with the need for frequent, sometimes not easily predictable, clinical interventions.

During a planned Leadership Walk round it was identified that there appeared to be issues with patients’ treatment being deemed unnecessarily escalated who were approaching the end of their life. Other factors identified during the transfer process were the lack of treatment plans, recognition or assessment of the palliative identity or needs of these individuals. These complexities and lack of recognition of palliative care needs were having an impact on establishing and implementing an individual’s wishes in regard to their plan of care.

This project focused on enhancing the experience for patients and their families with generalist palliative care, death, dying and bereavement needs, through the provision of specialist palliative care support/education for nursing and medical staff within MacMillan Ward.

Posted on June 21 2019 at 10:48

Poster Abstracts of the Month: April

The SPPC Annual Conference in 2018 featured 48 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on six of these:

Evaluating the Safer Prescription of Opioids Tool (SPOT) in clinical practice

Author(s)

S Botros; Dr D Buchanan; Sir A Cuschieri; Dr R Flint; J Forbes; Professor J George; Dr S Jamieson

Introduction and Aims:

The study evaluated The Safer Prescription of Opioids Tool (SPOT), an app-based equianalgesic opioid conversion tool as a clinician decision support (CDS) platform in opioid dose conversion using clinical data across primary, secondary and tertiary care in a palliative care setting at a Scottish Health Board.

Methods:

This prospective clinical utility single-centre pilot study followed a mixed methods design. Prescribers were asked to complete an initial survey to explore their current opioid prescribing practice in palliative and end-of-life care. Thereafter, prescribers were asked to use SPOT for opioid dosage conversions in parallel to usual clinical practice. Lastly, prescribers were asked to evaluate SPOT through a survey and follow up focus group.

Results:

62% of conversions were for cancer pain and 72% for 24 hour-daily dose conversions. SPOT correctly matched the Gold Standard result in 258 of 268 (96.3%) calculations performed during the study period. Users had a statistically significant increase in confidence in prescribing opioids after using the tool.

Conclusions:

The data from the study highlights the role of CDS when users prescribe high risk medicines. Almost all of those participating in the study would double-check their equianalgesic opioid conversion calculations if there was a simple, quick and safe option to do so, reflecting a pressing clinical need in a high-risk prescribing environment.

Foundations in Palliative Care: A Programme of Facilitated Learning for Care Home Staff and Home Carers

Author(s)

Ali Humphries; Suzanne Nimmo; Shannon Rendall; Karen Stewart

High quality palliative and end of life care delivery across Scotland should be the gold standard, but to achieve this there must be robust education and training in place to support all health and social care staff to achieve this goal.

The Strategic Framework for Action on Palliative and End of Life Care (2015) highlights that everyone should have access to palliative and end of life care but acknowledges that there are challenges for staff to be released for training. Similarly, Macmillan Cancer Support in Scotland have also outlined in their priorities that people with palliative and end of life care requirements should have their experience improved, but to do this, we must develop and integrate the wider cancer workforce.

In order to improve the palliative and end of life care experience of people throughout Scotland, Macmillan Cancer Support commenced an educational programme in November 2017. The Macmillan Foundations in Palliative Care resource pack (FIPC) underpins the delivery of this training to Care Home and Care at Home staff.

To date we have provided 15 courses throughout Scotland and have trained 209 people.

This poster outlines the rationale for the above project and provides evidence of the preliminary qualitative and quantitative results.

Hospital Doctor's Experience of Caring for Dying Patients: Report of themes from free text responses

Author(s)

D Gray; G Haworth; H Hood; G Linklater; C Smyth

The aim of this study was to examine, by means of a postal questionnaire, the experience of all grades of doctors caring for patients dying in an acute hospital in Scotland. There was an overall 42% response rate (127/306). Of responding doctors 55% had cared for 10 or more patients in the previous year. A quarter of respondents had personal experience of bereavement out with clinical practice within the previous year. 65% of responding doctors agreed that their most memorable patient death had had a strong emotional impact upon them. Responding doctors reported benefit from peer support. There was no association between length of time as a doctor and difficulty rating for talking to patients about death (p-value 0.203). There was no association between difficulty rating and length of time working as a doctor when talking to relatives about death and dying (p value 0.205). The questionnaire enabled respondents to provide further information in relation to their own experience and the response have been grouped into themes and reported in this poster.

Impact of population ageing on end-of-life care in Scotland: Population based projections of place of death and recommendations for future service provision

Author(s)

Anna Bone; Catherine Evans; Anne Finucane; Barbara Gomes; Irene Higginson; Richard Meade; Scott Murray; Tim Warren

Background:

Due to global population ageing, we are expecting a rise in the number of deaths, with implications for service provision in care settings.

Aims:

To project where people will die from 2017 to 2040 across all care settings in Scotland, and identify expert recommendations in response to projected trends.

Methods:

Population-based trend analysis of place of death and a consensus group meeting.

Results:

Annual deaths in Scotland are projected to increase by 15.9% from 2016 to 2040. Between 2004 and 2016, proportions of home and care home deaths increased, while the proportion of hospital deaths declined. If current trends continue, the numbers of deaths at home and in care homes will increase and two-thirds of patients will die outside of hospital by 2040. To sustain current trends, recommendations included: 1) increase, equip and sustain the health and social care workforce 2) to build community capacity and resilience and 3) to hold a realistic national debate on funding of palliative care.

Conclusion:

End-of-life care provision in community settings needs to increase by over 60% by 2040, otherwise hospital deaths will increase. Investing in a community-based health and social care workforce; and identifying and supporting informal carers are crucial.

Improving identification of people who could benefit from a palliative care approach

Author(s)

Paul Baughan; Michelle Church; Laura Dobie

The current situation is that many people across Scotland are not being identified and not receiving palliative care. There are lots of different tools that support earlier identification. So, one of the things that we have done in Healthcare Improvement Scotland is to try and make sense of which tool to use in which situation. We've produced the Palliative Care Identification tools comparator, which explains what tools are available, how they work and provides a decision tree that can help services decide what tool would best suit their aims.

Improving Palliative Care for People who are Homeless in Scotland - Possible Solutions

Author(s)

Joy Rafferty

There is need to consider how palliative care services can be more accessible and responsive to the needs of people who are homeless in Scotland. Review of published and grey literature, online searches and networking identified ongoing projects/services providing palliative care for homeless people in developed countries worldwide. These were examined, looking for examples of good practice and consideration made of transferability to the Scottish context. Eleven types of projects were identified aiming to improve palliative care for people who are homeless. One solution is unlikely to meet all the needs of this complex varied group with combinations of different services ideal. There is scope in Scotland to engage with specialist GP practices for people who are homeless and provision of support and education to staff working with this group. Consideration should be given to developing respite/intermediate care beds in culturally appropriate settings (e.g. homeless hostels), which can be utilised for those with palliative care needs. With many homeless people affected by profound and complex loss, specialist bereavement support can be helpful. Homeless people are unlikely to proactively access services so effective outreach involving relationship building and partnership working with other services is vital.

Posted on April 30 2019 at 11:31

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