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: June
The SPPC Annual Conference in 2015 featured 38 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:
- Macmillan Rural Palliative Care Pharmacist Practitioner Project (MRPP): Phase
- No decision about me without me’
- ‘No specialist and no out of hours service!’ – Audit and experience of end of life care in a rural Australian hospital
- Patient and family experiences of DNACPR discussions: an integrative review of the literature
- Person Centred Care at the End of Life: Developing a care plan for End of Life Care in a hospice setting
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.
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.
Exploring the importance of creative activity to palliative care
The successful creative arts service at The Prince & Princess of Wales Hospice is opening its doors to figures from the world of arts and heatlhcare.
To celebrate Creativity and Wellbeing Week, from June 13 to 19, the relevance of creative activity to palliative care will be explored by invited guests, from artists working within healthcare to palliative care professionals.
The idea is that the workshops, which offer guests the chance to explore different art materials and mark-making techniques, will open conversations between professionals with an interest in palliative care, arts and health.
John Jones, 54, from Govan, Glasgow, has been a day services patient at Glasgow’s Hospice since early 2015 and rediscovered a long-forgotten love for art.
“I always enjoyed art at school and my teachers wanted me to take it further but I left school and started work,” he said. “I went on to work at the Rogano restaurant, I started off as a page boy, and was then a waiter and went on to do bar work.”
He works with watercolour crayons to create bright, lively pieces of artwork, two of which hang on the walls of the hospice’s art room.
"I enjoy the peace and quiet to work in the art room, it takes your mind off other things that are going on in your life,” he added. “I look forward to going to the art room, it give you a different interest. You try not to think about what’s going on in your life and carry on as normal. The art room takes your mind off things.
“The artists are excellent, they give you help and advice. I’ve got a few pieces at home now and some on the walls of the art room.
“It is uplifting, I’d definitely recommend it. A lot of people come into the hospice and it’s not for them but many find they’re good at it and you’d think they had been drawing and painting all their lives. It just seems to come naturally.”
John Kelly, 77, from Govanhill, Glasgow enjoys painting landscapes.
“I’ve been coming to day services at the hospice every week for about six months. Staff asked me if I wanted to go to the art class and I thought I’d give it a try,” he said. “I like painting landscapes and architectural pieces. One of the first ones I did was of the monastery on the isle of Mull, it had a lot of intricate work.
“I enjoy the company in the class. I don’t get out much at home, there are things I used to do that I can’t now. The class is relaxing.”
Initially set up in 2003 to address the absence of art in palliative care in Scotland, the artists who staff the project worked from a table in the corner of day services. It has grown and thrived to become a fully integrated key service with its own art room.
The creative arts service includes visual art and creative writing workshops and is open to all patients, family members and carers registered at the hospice.
There are patient art workshops, in which individual projects are undertaken within a group, as well as private family art workshops for adults and children, a carer’s drop-in workshop, and individual patient creative writing workshops.
The service aims to give people the opportunity to develop their creativity, express themselves and try something new while engaging in a relaxing and meaningful activity during a difficult time in their life.
It gives people back some of the control they have lost through illness, disability and caring responsibilities. Unlike art therapy the intention is never to analyse or explore issues raised by the creative process.
Most people who access the creative arts service at the hospice have had no previous experience, or have been forced to give up creative pastimes through ill health. Their attendance might offer respite for the patient, family member of carer, a therapeutic activity or a focused activity with their peers.
All sessions are patient-led and supported by qualified practicing artists who have extensive experience in the arts and health, specifically in palliative care, and have ongoing art practices of their own.
“When we meet people they have often lost a lot of confidence and are going through a very difficult time. In the art room they are in charge of every mark they make. We are there to encourage and support participants to develop their own creative practice as artists in their own right, where ideas and skills can grow over time,” said artist Jeni Pearson.
“It can offer those involved an increased sense of wellbeing. Art has the ability to help us view the world through new eyes. I have heard so many of our participants say that they look at things differently now and for many it can be a life-enriching experience, and this has to be of great importance within the context of palliative care.”
The hospice is currently fundraising to build a new hospice in Glasgow’s Bellahouston Park that will offer the very latest techniques in palliative care. Art will be an integral part, with gallery space for patients’ work.
By: Angela McManus, Communications manager, Prince & Princess of Wales Hospice
Picture credit: Nick Ponty
Enhanced End of Life Care in Ayrshire Nursing Home
The Abbotsford Nursing Home in Ardrossan has been providing meaningful and sensitive care for its residents for almost 30 years in North Ayrshire.
Recently, we have developed a new service, Enhanced End of Life Care, for when a person is no longer able to be supported at home (for instance, due to carer fatigue), or the person has been admitted to hospital but would prefer his/her place of care to be closer to home, family and friends.
In a close working partnership with District Nursing, G.P.'s, NHS Specialist Palliative Nurses and The Ayrshire Hospice Specialist Palliative Care Community Nurses, we respond to provide a comprehensive form of palliative care in an informal, relaxed environment. Our holistic approach includes pain and symptom management and nursing care in a dedicated en-suite bedroom
facility, as well as accommodating the person's spiritual, emotional and/or social support needs.
Our Enhanced End of Life Care service has been developed with strong support from Specialist Palliative Nursing teams at The Ayrshire Hospice and the NHS, local District Nursing teams and Macmillan Cancer Support. This collaboration is providing support and assistance both operationally and with additional knowledge and skills development for our team in Abbotsford.
It is free to the service user and is funded through the Scottish Government's Integrated Care Fund. We were awarded this funding by the North Ayrshire Health & Social Care Partnership and it is currently for one dedicated en-suite room facility. This initiative will enable local people in the advanced stage of their illness to be cared for twenty four hours a day in closer proximity to their family, friends and within their community. The service can be offered to people who would
prefer this choice and where their life expectancy is limited. However, should the person's symptoms stabilise, it is anticipated that a return to home will be a positive outcome, allowing the service to become available for another individual and his/her circle of friends and family.
If you would like more information on this new, innovative service, please contact Louise Pettigrew, Registered Manager, or her Depute, Georgette Langan, on 01294 602915 or by email.
By Nigel Wanless, Abbotsford Nursing Home
Macmillan Pharmacy Service Annual report
The Macmillan Pharmacy Service has published its Annual Report for 2014-15.
The service has now been rolled out across all Health and Social Care Partnerships within Greater Glasgow and Clyde. The expansion began in August 2013, following successful evaluation of the Macmillan Pharmacy Facilitator pilot project (2009-2013), by the University of Strathclyde.
The overarching aim of the service is to support community pharmacy and the wider primary care health and social care team to advance person-centered, sustainable, high quality, safe and timely pharmaceutical palliative care (PC) services as close to home as possible for patients, carers and families.
The idea is to shift the balance of care away from the acute sector to a more financially sustainable community based services that will better serve the growing ageing population, reduce pressure on out-of-hours services and avoid emergency hospital admissions.
The annual report is available for download here: Macmillan Pharmacy Service Annual Report.
Poster abstracts of the month: February
The SPPC Annual Conference in 2015 featured 38 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:
- Improving Discussion and Documentation of CPR and Escalation Status in the ECC
- Key Information Summary Access and Anticipatory Care Planning in Secondary Care: A Quality Improvement Project
Improving Discussion and Documentation of CPR and Escalation Status in the ECC
Background: Escalation planning and CPR decisions not always considered early enough in patient journey, potentially leading to suboptimal care.
Aim:To assess the standard of documentation in inpatient notes across the ECC wards relating to the discussion of resuscitation and escalation status.
Results: 46 patients’ notes reviewed. 9/46 had DNACPR form of which 6/9 had documented discussion with family. 4/46 patient's had documentation of escalation status. 7/9 forms countersigned by consultant & 3/9 had review date completed.
Summary: If decision for DNACPR has been made then in general all completed and discussed correctly. Poor documentation of any advance planning or DNACPR discussions.
Future - Introduce a Treatment Escalation Plan proforma to the ECC to prompt and aid discussions about escalation and CPR. This work is ongoing.
Key Information Summary Access and Anticipatory Care Planning in Secondary Care: A Quality Improvement Project
Authors: Dr Charlie Hall; Dr Juliet Spiller
The electronic Key Information Summary (KIS) is a vital way of conveying Anticipatory Care Information from Primary to Secondary care. For patients with Anticipatory Care plans, Special Notes and electronic Palliative Care Summaries are now available to hospital teams readily via the KIS.
Using the PDSA approach we undertook audits and interviews to assess: KIS prevalence among patients admitted to a Medical Admissions Unit (MAU) and content of the KIS. We assessed levels of clinician access to the KIS, their opinions of the usefulness and also barriers to accessing the KIS. Evidence of Goals of Care (GOC) discussions with patients at risk of deterioration or dying were also assessed.
The majority of hospital clinicians thought the KIS was useful but many did not know how to access it. Interventions were subsequently trialled including: Education and awareness, trial of an 'Anticipatory Care Planning tab' and introduction of the SPICTTM tool to MAU admissions booklets.
Re-audit showed a significant increase in access to the KIS on admission, but mixed results regarding the use of the new admission documentation and GOC discussions. Further PDSA cycles to test sustainable interventions throughout NHS Lothian are discussed and recommendations made.
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