Sharing Current Scottish Practice

01. A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or short CAM?

Author(s)

Baird L and Spiller J

Prevalence studies show that 15-42% of patients admitted to specialist palliative care inpatient units have delirium. Symptoms of delirium are often subtle and easily missed, or misdiagnosed as fatigue or even depression, and so the use of a screening tool could improve early identification and management of delirium and lead to improved outcomes. Patients admitted to the hospice are often frail and tired; therefore a quick and easy to use method of cognitive assessment is essential. A quality improvement approach was used to improve screening for delirium on admission to a hospice unit. The first cycle determined staff preference between the short CAM and the 4AT. Two further PDSA cycles embedded the 4AT (our preferred tool) into the admission process, establishing it as a usable tool in the hospice setting for up to 92% of admissions. A subsequent cycle showed poor sustainability prompting improvements to staff education and changes to admission documentation. The QI approach highlighted the need to link staff awareness of their use of the screening tool with perceived improvements in treatment of delirium which prompted the creation and implementation of a delirium checklist in the unit, which details the management of delirium, common causes and suggested investigations.

02. Addressing the Great Taboo

Author(s)

Alexander H and Beuken G

This short session was designed to address the taboo of talking about death, dying and bereavement. Although it had not been tried before and there were concerns that some participants may be distressed by the content, the observation results show that this was not a big problem. Participant responses during the session show that the audience knew quite a lot about the topic. This is helpful for peer learning but also because the session was designed as a structured conversation to encourage people to discuss the subject more openly, some mentioned that they planned some actions as a result of attending e.g. making a will or discussing their own funeral wishes with their family. Feedback from the end of the session showed that most people found the session very interesting, although others had mixed reactions, saying it was also challenging. In total 81% of those present requested more training, which indicates a strong desire for more. Some degree of discomfort was expected, however, the session appears to have been very positively received by most participants. There was a small level of not unexpected upset, and a strong desire to learn more.

03. Aiming to achieve realistic bereavement care throughout Greater Glasgow and Clyde

Author(s)

Dolan J, McNeill K, McVey H, Miller J and Neeson E

Introduction: ‘How people die remains in the memory of those who live on’. Facilitating a good death can impact positively on grief and bereavement.

57% of deaths in Greater Glasgow and Clyde occur in acute hospitals, as health care professionals we are in a privileged position to strive for good deaths. Enabling practitioners to be open and equipped to talk about death, dying and bereavement reduces negative experiences.

Aim: To increase practitioners’ confidence and competence when dealing with death, dying and bereavement.

To raise awareness of resources and processes to improve the experience of those affected by death, dying and bereavement in all care settings

Methods: Following a theoretical palliative care module practitioners returned to improve practice through various projects (in ITU, paediatrics, acute surgical receiving , orthopaedics, ENT, tissue viability, respiratory and general medicine), aiming to improve the patients and relatives experience of death, dying and bereavement out with specialist palliative care environment

Projects included:

ž memory making in the form of hand prints, hair and jewellery in organza bags

ž brightest star bereavement boxes

ž death certification checklist

ž raising awareness of resources and processes

ž care after death boxes.

Next steps: Secure funding to embed projects in daily practice, continuing partnership working

04. Approaches to delivering palliative care in nursing care homes in the UK: a systematic scoping review

Author(s)

Finucane A, Hockley J and Kohli-Lynch N

The UK population is ageing with more elderly people living and dying in nursing care homes, making these important settings for palliative care interventions. Multimorbidity and dementia are common and many residents will have high symptom burden and complex care needs. A scoping review was undertaken to map palliative care interventions in nursing homes in the UK. This involved systematically searching six databases from January 2000 to February 2016. 17 articles were identified. These consisted of 7 evaluations studies, 7 descriptive or observational studies and 3 implementation studies. The studies focused on palliative care pathways, advance care planning, staffing issues and healthcare links across settings. The majority of studies were focused on staff views with few focussing on residents’ experiences. However overall there was a paucity of research on palliative care interventions in UK nursing homes. An increased emphasis on developing and evaluating palliative care interventions that are informed by the needs and preferences of resident’s and family’s experiences is recommended.

Situation: Despite the increasing incidence, challenge and cost of dementia care, questions remain about how to improve the quality of living and dying for people with end-stage dementia. In response, ACCORD Hospice has been involved in exploring the impact of Namaste Care™ since 2011.

Background: Namaste Care™ is an emerging multi-sensorial model of palliative care designed to improve the quality of life for people with advanced dementia. It has been demonstrated to: facilitate moments of meaningful connection and engagement between people with end stage dementia and others; promote hope among family members; and increase job satisfaction among care staff.

Assessment: As a result of Accords’ project work local interest in Namaste Care™ was high, but knowledge and understanding was low. Therefore an experiential course (with a placement opportunity) was developed by ACCORD Hospice.

Result: The first four day course was delivered in partnership between ACCORD Hospice, The Ayrshire Hospice and Adams House Care Home in 2014. This resulted in two further Namaste Care™ programmes being launched in care homes (with hospice support). Two more courses are planned over the next 12 months (with the support of Adams House in Renfrewshire and Abbotsford Care Home in Ayrshire). The projection for 2016 is: three new care home programmes to launch in Renfrewshire (with educational support from ACCORD Hospice) and two more programmes to launch in Ayrshire (with educational support from The Ayrshire Hospice). Ayrshire sites include a learning disability unit and a mental health care setting for people with dementia.

Author(s) NHS Highland/Macmillan Team: Alison MacRobbie; Gill Harrington

University of Strathclyde Team: Professor Marion Bennie; Dr Gazala Akram; Emma Dunlop; Dr Rosemary Newham

In 2012, NHS Highland aimed to explore a new service model piloting the development of a full-time Macmillan Rural Palliative Care Pharmacist Practitioner (MRPP). The aims were to develop community pharmacy to support the needs of palliative patients, improve service provision, develop training and peer support opportunities and provide quality information to support practice. Phase 1 explored service gaps and key issues and has previously been published.

Phase 2 aimed to investigate new areas of service, develop evidence-based resources for healthcare professionals and patients, and provide a set of recommendations upon which the service could be developed further. A mixed case study approach was used for evaluation and results were summarised under two key areas; ‘Education, Training and Awareness’ and ‘Integration of the MRPP in the Multi-Professional Team’. Within these areas were included development of a series of training resources, ‘Sunny Sessions’ for Care Home Staff, and mouse mats and mugs containing palliative care prescribing information for healthcare professionals. There was enhanced pharmaceutical presence at multidisciplinary meetings and access to patient medicine information.

For NHS Scotland the evidence from this project presents a clinical practice model for community pharmacy palliative care services in rural areas in line with existing key health policy.

'No decision about me without me’

Author(s): A Todd; A Pringle; S Keir

Introduction: Ensuring patients have as much input as they wish into their care is a fundamental aspect of good medical practice and as such the Department of Health advocates shared-decision making (ISBN: 13:9780101788120). Recent legal rulings highlight the willingness of the public to hold health services to account should they fail in this regard ([2014] EWCA Civ 822).

Aims: To evaluate the introduction of an anticipatory care plan (ACP) form on both the degree of shared decision-making with multi-morbid patients and their families, and the speed at which on-call teams could access this information for timely treatment decisions.

Methods: Via small tests of change, an ACP form was designed that documented four key decisions concerning response to deterioration (figure 1). Central to the form was a box recording date of discussion with the patient or next-of-kin. We measured the frequency of shared decision-making before and after the introduction of the ACP form.

Results: Shared decision-making increased. The time to find all key information significantly reduced informing appropriate response to deterioration.

Conclusion: The introduction of an ACP form encouraged shared decision making and facilitated out-of-hour assessments. The presence of the form provided a forcing function that triggered more discussions.

‘No specialist and no out of hours service!’ – Audit and experience of end of life care in a rural Australian hospital

Author(s): Natasha Freeman

Palliative care provision in Kempsey Hospital consists of a specialist nurse consultancy service, no inpatient or community beds, no afterhours or weekend support and no specialist physician cover. Local GP’s estimate 40% of palliative care patients require end of life care in hospital. We audited end of life care standards for inpatients and surveyed staff opinions on current end of life care practice.

Our patients ranged from 35 – 85 years, and 8% were Indigenous Australians. We showed that less than half of patients had a complete physical assessment of symptoms, had anticipatory medications prescribed and had spiritual needs addressed. Nearly 70% of nurses believed a new end of life care pathway was required and 85% requested more education and support in palliative care practice.

A redesigned end of life care pathway is being introduced to improve standards not currently being met. Our findings highlight the need for developing innovative educational programmes on end of life care for rural nurses, and video conferencing is being explored as a means of delivery. In response to the current lack of specialist service in Kempsey, locally designed and tailored educational programmes are being developed aimed at strengthening current hospital and community expertise.

Patient and family experiences of DNACPR discussions: an integrative review of the literature

Author(s): Dr CC Hall; Dr E Carduff; J Lugton; Dr J Spiller

The aim of this review is to identify patient and family views on the communication of DNACPR decisions based on their experiences of DNACPR discussions. A literature search of multiple databases was performed for (adult) patients, from all countries over the last 10 years. 559 abstracts were identified. After coding and exclusions were applied, 46 relevant full texts were included (9 UK, 37 rest of world). Cultural variations were considered and recurring themes were tabulated.

Themes revealed the importance of DNACPR discussions being held by someone trusted and the importance of family/ carer involvement, as well as perceived concerns about burdening family members. Timing of discussions revealed the difficulty of finding the ‘right time’ to discuss DNACPR. For certain patients earlier is preferable (e.g. in elderly patients while cognition is good) where as cancer patients prefer not to discuss DNACPR close to diagnosis or starting treatment.

Discussions held at home or at the GP surgery were preferable to discussions held during acute admissions to hospital. Content of discussion highlighted the importance of discussing prognosis and quality of life with patients. Also that patients find discussing DNACPR in the context of a wider discussion around treatment escalation options acceptable.

Person Centred Care at the End of Life: Developing a care plan for End of Life Care in a hospice setting

Author(s): Kim Donaldson; Vicky Hill; Duncan Brown

Recognising dying, and caring for people at end of life, is often challenging, uncertain and emotive for all involved1. Striving to ‘get it right’ when you only have one chance is a fundamental attribute of professionals.

Having successfully used the Liverpool Care Pathway (LCP) to guide the care offered to dying people and their families, St Columba’s Hospice (SCH) appreciated the importance of taking a considered approach in moving forward after the LCP planned phase out in 2014.

A working group critically reviewed the literature and undertook a rigorous consultation with clinical staff, non-clinical staff, volunteers, patients and families to elicit views on what mattered most at the end of life. An openness from colleagues across Lothian to share their work and review the work of SCH was invaluable.

This poster illustrates the development, implementation and initial evaluation of the SCH Person Centred Care at the End of Life document.