Sharing Current Scottish Practice

Poster abstracts of the month: April

The SPPC Annual Conference in 2014 featured 40 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 the experience for bereaved families by developing a process for issuing death certificates
• Integrated and coordinated discharge planning for palliative patients
• Its time to talk about death and dying
• Location, location, location
• Macmillan rural palliative care pharmacist practitioner project

Improving the experience for bereaved families by developing a process for issuing death certificates

Poster abstracts of the month - February

The SPPC Annual Conference in 2014 featured 40 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:

Dining with Death Conversation Menus

DNACPR decisions in Lothian Care Homes

Educational Visit to the Crematorium for Hospice Staff

Enablers and Barriers to Volunteering in Care

End of Life Care in Liver Disease

Dining with Death: Conversation menus as a means of educating people about death, dying and bereavement

Author(s) of poster: Mark Hazelwood, Rebecca Patterson

There is growing consensus that palliative care encompasses a ‘health promoting’ element concerned with encouraging openness about death in society so that people are aware of ways to live and support each other with death, dying and bereavement.

A general societal reluctance to engage with these issues makes it harder for clinicians to initiate timely discussions with patients about their end of life care wishes.

However, finding ways to educate wider society in issues relating to death and dying can be problematic in a culture where raising these issues is variously perceived as too morbid, too difficult or too sensitive to mention.

This poster describes the Dining with Death menu and some of the settings in which it has been used, exploring its potential as an experiential learning tool to enable people to become more open about discussing death and dying.

The Dining with Death conversation menu is a folded piece of A4 card, printed with three ‘courses’ of suggested conversation topics, for example ‘Cremation or burial?’; and ‘What would be in your death plan?’.

It can be used to overcome barriers to engagement in death discussions, intriguing participants and engaging them in non-threatening conversations.

DNACPR decisions in Lothian Care Homes: An audit of current practice

Author(s) of poster: Alice Radley, Lesley Bull, Anne Finucane, Janet Dobie, Sarah Shepard, Marlis Plumb, Louise Wood, Juliet Spiller

Introduction: Care home residents are often frail with multiple co-morbidities. Advance Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are important in this context to help avoid inappropriate resuscitation attempts at the end of life.

Aim: To examine DNACPR decisions in care homes and compare with six good practice standards.

Methods: An audit of 160 residents from 48 care homes across Lothian, between April 2013 - March 2014. Notes of recently deceased residents in whom death was anticipated were audited.

Results:

• All audited residents had a DNACPR decision.

•No residents with DNACPR forms had resuscitation attempted prior to death.

•50% (n=80) of DNACPR forms had a documented review time frame.

•99% (n=159) of DNACPR forms were signed by a senior clinician within 72 hours of completion. 96% of these were signed by a General Practitioner.

•A clinical DNACPR decision was discussed with 68% of residents or their family.

Conclusions:

•GPs play a central role in facilitating DNACPR decisions in care homes.

•Clearer guidance may be needed regarding the review of DNACPR decisions.

• Discussions with patients and their families about DNACPR decisions are sometimes documented but we highlight an urgent education need in light of a recent Court of Appeal judgement.

Educational Visit to the Crematorium for Hospice Staff

Author(s) of poster: Stuart Murdoch, Hospital Chaplain, Dr Erna Haraldsdottir

Background: It is well recognised that in order to care in an open and honest way for those who are dying and their families health care professionals need to be confident in speaking about issues related to the process of dying, and there are educational needs related to this.

Aim: Develop and deliver an education session, informing hospice clinical staff in relation to the actual processes of cremation to enhance their confidence and ability to support and inform patients and families who wish to talk about the option of the patient being cremated.

Methodology: Visits to the crematorium were organised for maximum 10 staff members per visit, with 39 attending in total lasting for 1 hour and evaluated with questionnaires after the visit.

Results: 19 participants filled out and returned the questionnaire. 17 responded that the visit was Very Informative, and 2 Informative. Key themes emerged were a greater understanding of the cremation process, increased confidence to journey with patient & family’s regarding the cremation process, dispelling myths and understanding of the cremation process, opportunity to explore own personal journey regarding death & dying.

Conclusion: It is evident that educational input around the post death process is highly valuable to staff in terms of building their confidence to journey with patients and their families at end-of-life

Enablers and barriers to the involvement of volunteering in care

Author(s) of poster: Ros Scott, Richard Carling, Jean Hindmarchx

Background: Together for Short Lives and Help the Hospices undertook a joint project exploring the future development of volunteering. As part of the project data was gathered from hospice professionals and volunteers on the barriers and enablers to the development of volunteering in care. This poster describes the findings and the outcomes of the project.

Findings: Responses highlighted a significant involvement of volunteering in care and a clear commitment to further development in this area. Barriers to the development of volunteering included, staff concerns, lack of resources, ability to deliver training to both volunteers and staff, and providing effective support and supervision. Enablers to the development of volunteering in care included: sharing policy, practice, experience and resources, national initiatives and the development of readily available training packages.

Outcomes: There is clearly a willingness to further develop volunteering in adult and children’s palliative care and some clearly identified requirements. A resource was developed based on these findings which combined guidance, signposting and an evaluation toolkit. Case studies from UK, Netherlands and Austria were used to illustrate throughout.

End of Life Care in Liver Disease

Author(s) of poster: Sally Lawton

The key to delivering appropriate palliative and end of life care is the identification, assessment, monitoring and planning of care. We wanted to know if this approach was being used for patients dying of chronic liver disease. The poster displays findings from an audit project that reviewed the notes of twenty patients. It also poses some questions for discussion within the liver service.

Supporting Physical Activity Participation in Palliative Care

Introduction

Research evidence shows that remaining physically active throughout life can improve quality of life and the ability to manage at home including activities of daily living and walking .

Physical activity participation is now promoted by government, healthcare providers, charitable and professional bodies. Research evidence and media awareness of these benefits has led to calls for more community based programmes to assist people living with long term conditions to manage their condition, maintain their quality of life for as long as possible and reduce burden on health service resources. ("Move More" above - Macmillan Cancer support 2014)

Our project to develop physical activity programmes for patients with palliative care needs began in 2010 when staff from Macmillan Day Care in Dundee attended the Scottish Macmillan Conference. We learned of the evidence, presented by Dr Anna Campbell, which exists to support physical activity in the control and prevention of symptoms of people living with a cancer diagnosis.

An exercise programme was already available in Macmillan Day Care for patients with advanced chronic obstructive pulmonary disease (COPD). Due to increased awareness of the benefits of exercise and cancer management, some of the patients with lung cancer were also keen to access the exercise class. The task was working out how to implement this generic class for patients with a wide variety of conditions, all at different stages of disease trajectories.

Methods

The opportunity to develop this idea arose through training offered by NHS Tayside ‘Practice Development Apprenticeship Scheme’. This was an opportunity for staff to engage with practice development, and to develop leadership and putting evidence into practice skills, whilst developing and implementing a practice development idea into a practical reality.

The apprenticeship was supported by the Allied Health Professions Directorate in NHS Tayside, led by Dr Jacqui Morris, AHP Research and Practice Development Lead NHS Tayside. The project was funded by monies from the Chief Health Professions Officer and following a recruitment process 6 AHPs were selected.

We met twice monthly for 6 months, learning about systematic review, evidence synthesis, process mapping, project planning and measurement and data analysis. The aim has been to train us to become leaders of practice development in our own clinical areas and assist others to develop their own ideas in service development.

We completed a literature review of the evidence for physical activity in a palliative care setting and discovered there was evidence showing that physical activity not only improves physical performance in most conditions but can also improve quality of life.

The aim of our project was to improve access to the exercise class for all patients and it was important that this service be offered to all patients based on their need not diagnosis. The challenge for us as clinicians working with such a diverse group of patients at varying stages of their disease trajectories was to ensure the intervention was clinically effective, safe and maximised our use of NHS resources.

It became apparent that the pulmonary and cardiac patients were well educated in their ability to self-manage their symptoms, based on their previous experiences of rehabilitation. However, the cancer patients in general were often fearful of physical activity, deconditioned and frequently reported they had spent the last 2 or 3 years ‘mostly sitting’ after treatment stopped. These patients continued to need healthcare professional support to help ‘pick up the pieces’ of their lives and move on.

We knew evidence existed to support appropriate exercise therapy in palliative care but what we didn’t know was how best to deliver it based on patient choices and preferences. The apprenticeship scheme offered the support and direction to ensure we gathered the appropriate evidence so that when the project completed in Oct 2013, we had the evidence which would help direct the service.

To do this it had been crucial to develop a ‘patient engagement plan’ in which we informed, engaged with and then consulted the patients who accessed the day care service.

We provided education sessions to teach patients the benefits of keeping active, set up focus groups with patients and asked what preferences they had for physical activity based on Macmillan Scotland’s recommendation of exercise groups, walking programmes and Chi Gung as suitable forms of physical activity for this patient group.

As we developed information leaflets about the services on offer, patients were asked for feedback throughout the process to ensure that what we were providing was what the patients wanted and understood. Emotional touchpoints were used and conveyed very powerful feelings from the patients relating to remaining physically active. Many of the patients felt very positive about helping to shape the service and were genuinely pleased to be involved.

Unless individual treatment is indicated, we can now offer exercise therapy in a group. In this way we can manage a full day’s list of patients in 1 ½ hours with much added benefit of group therapy and peer support for the patients.

Results

In line with the evidence, our outcome measures show improvement in functional performance and quality of life. Almost all patients have expressed an interest in walking programmes and Chi Gung and Macmillan has now offered Chi Gung training for staff to provide this on a long term basis. This will likely be beneficial for the frailer patients to avoid long periods of inactivity.

In line with patient preferences that we obtained through the project, we are now developing walking routes around Specialist Palliative Care Services. Paths For All have provided walk leader training for staff for the carefully identified bronze, silver and gold walking routes, to help build up patients levels of activity in a supported a safe environment.

Conclusions

As patients with life-limiting conditions are living longer with better symptom control, trying to find new ways to offer evidence based interventions to cope with this predicted increase in demand for rehabilitation is an on-going challenge.

An equitable service for all patients who require it should be offered as early as possible in the patient pathway, optimising the ‘teachable moment’, usually at diagnosis when health behaviour change can be facilitated most readily.

Now, we aim for 100% screening of physical activity levels of all patients referred to the day care unit and offer advice in line with the Scottish Physical Activity Pathway.

The apprenticeship scheme has turned ‘an idea’ into a sustainable reality now and hopefully long term into the future. There has been lots of learning, lots of hard work and lots of reward to see patients benefit, maximising functional performance, minimising symptoms and promoting quality of life, throughout life.

Mandy Trickett, Macmillan Specialist Physiotherapist,NHS Tayside

Contact: email or telephone: 01382 660111 ext 26170

Poster Abstracts of the Month - January

The SPPC Annual Conference in 2014 featured 40 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:

Anticipatory Care Plans and preferred place of end of life care/death

Author(s) of poster: Yvonne Jones

Anticipatory prescribing at the end-of-life in Edinburgh care homes

Author(s) of poster: Anne M. Finucane, Dorothy McArthur, Hilary Gardner, Scott A. Murray

Art in Reflective Practice: 16 weeks, Reflections of a trainee in Palliative Medicine

Author(s) of poster: Angela Nelmes 

Clinical Psychologists in specialist palliative care: what do we actually do?

Author(s) of poster: Jenny Strachan, Anne Finucane, Juliet Spiller

Day Therapies: Promoting Health and Well-being in Palliative Care