Sharing Current Scottish Practice

Building on the Best – Improving palliative and end of life care in acute hospitals in Scotland

Author(s)

Kirsty Boyd; Deans Buchanan; David Gray; Trisha Hatt; Mark Hazelwood; Barbara Kimbell

The Need for Action

At any point nearly 1 in 3 hospital beds in Scotland is occupied by someone who will die within 12 months. There is a need to refine processes and to support staff to deal with this large and often complex area of work. There is also a need to prepare and support people and their families to cope with the hospital experience.

What We Did

As part of a UK-wide programme funded by Macmillan a project manager was employed by SPPC. She worked with ward staff in 3 Scottish acute hospitals with the aim of scoping practice and supporting identification and testing of improvements. The project manager also sought input from people, relatives and public. The work was guided by local palliative medicine leads but led by staff of other specialities.

Results

The commitment of general acute staff was strong, but the pressured environment meant work was slow. To varying extents wards identified and tested changes in process and/or practice. A suite of resources to prompt and support staff/individual conversations was developed and tested. Some ward processes were significantly changed in order to improve communication within the staff team.

Catastrophic Bleed Box - a practical resource within an acute setting?

Author(s)

Heather Tonner

Background:

Terminal haemorrhage (bleeding from a major blood vessel), although uncommon, causes significant distress for all involved when this catastrophic event occurs. The literature highlights the importance of good nursing care to lessen this distress. Harris et al (2011) suggest the management of terminal haemorrhage should focus on non-pharmacological, simple approaches.

Aim:

In response to traumatic events associated with catastrophic bleeding in an acute medical ward a catastrophic bleed box was developed for use across a District General Hospital.

Method:

• To facilitate discussion with ward teams regarding the care of patients at risk of terminal haemorrhage
• Identify patients at risk
• Enable sourcing of a catastrophic bleed box, including dark towels
• Provide support for staff involved in this distressing situation.

Results:

Feedback from staff that have used this resource has been sought as means of evaluation. The feedback has been extremely positive. Staff like a tangible way of preparing for a catastrophic terminal bleed. Qualitative comments imply that staff feel more confident having dark towels to hand to camouflage the blood and concentrate on calmly supporting the patient and family.

Collaborative working between renal and palliative care: The impact of an integrated service on symptom burden, advanced care planning and place of death for patients with advanced chronic kidney disease managed without dialysis.

Author(s)

Sarah Cathcart; Claire A Douglas; Lorna Frame; Maureen Lafferty; Joanne Sloan; Louisa Stage; Miles Witham

Background:

For elderly patients with comorbidity and chronic kidney disease (CKD), dialysis results in significant time spent in hospital and may not offer improved survival, compared to those managed without dialysis.

Renal and Palliative Medicine professionals developed an integrated Renal Supportive Care (RSC) service for patients with chronic kidney disease (CKD) managed without dialysis. The focus is care of CKD, symptom management and Advanced Care Planning (ACP).

The impact on symptoms and care pathways was evaluated over a 30-month period. Data collected included RSC input, Palliative Care Outcome Score (POS), ACP information and mortality data.

Results:

Those patients with RSC input had improved symptom burden. They were more likely to have improved documentation and electronic communication of ACP conversations than those without RSC input. This included Preferred Place of Care (PPC) and DNA CPR information. At end of life, those patients who had PPC documentation were significantly more likely to die in the community. Those without, were more likely to die within an acute hospital.

Conclusions:

The integrated Renal Supportive Care team achieved symptom management and Advanced Care Planning for many patients with CKD managed without dialysis and may help avoid acute hospital admissions at end of life.

Drug therapy for delirium in terminally ill adults: A Cochrane review

Author(s)

Bridget Candy; Anne Finucane; Louise Jones, Baptiste Leurent, Elizabeth Sampson; Paddy Stone; Adrian Tookman

Introduction:

Delirium is a complex neuropsychiatric syndrome common in palliative care, occurring in up to 88% of patients in the weeks or hours preceding death. Our Cochrane review on drug therapy for delirium in 2012 identified one trial (Candy et al. 2012). New trials have been conducted and an updated review is now recognised as a Cochrane priority.

Aim:

To evaluate the evidence from randomised controlled trials (RCTs) examining the effectiveness and safety of drug therapies to treat delirium in adults with a terminal illness.

Methods:

We searched for RCTs comparing any drug treatment with any other treatment for delirium in terminally ill adults.

Results:

We retrieved 9,431 citations. Four studies were included in the final review. All trials were vulnerable to bias, most commonly due to small sample size or incomplete outcome data.

Conclusion:

This review identified four trials. It found low quality evidence examining the impact of drug therapy on delirium symptoms and adverse events in terminally ill adults. Results for each comparison were based on single studies. Undertaking trials on delirium in this patient group is methodologically complex. Only one study compared drug therapy with placebo. This limited our ability to answer our review questions

End of Life Care is not Black and White

Author(s)

Rosemary Cairns; Jacqueline S Nicol; Laura Thomson

This poster illustrates the implementation of a Macmillan palliative care education resource in the acute setting. Originally developed for care home staff, this was adapted and tested in an acute setting within NHS Lothian.

The resource, Foundations in Palliative Care, comprises four modules: introduction to palliative care, communication, symptom management and bereavement. Education was delivered by the Education Lead for End of Life Care and a Senior Clinical Nurse Specialist, Hospital Palliative Care Team, four days delivered within two weeks. This was supported by Senior Management and Charge Nurses which enabled ten registrants to commit and attend all four modules.

Evaluation was extremely positive. Follow up visits from the course facilitators found participants had bridged the theory/ practice gap.

Enhanced Palliative Care for Generalists (EPCG)

Author(s)

Paul Baughan; Neil Pryde

Following feedback on the Scottish Palliative Care Guidelines, where there were comments that broader and more detailed guidance would be helpful, a proposal was taken to Macmillan to support the development of a training course for generalists.

The EPCG course will be an educational program based on the well-established model of a comprehensive, evidenced, manual underpinning a two-day interactive course.

We are preparing a pre-course manual, and an interactive 2-day course. This will include lectures, small group workshops, skill stations, and “real life” scenarios. There will be an assessment at the end.

The course will adhere to the principals of the NES framework for Palliative and End of Life Care and follow the general structure and the drug regimes of the Scottish Palliative Care Guidelines. The project has support from HIS, NES, and the SPPC.

A steering group has been established that will oversee the direction and co-ordination of the project. Class Professional Publishing will provide support and guidance throughout the project. Writing of the manual will be divided into seventeen sections. There will be a separate group to develop the interactive course. Finally, the materials will be peer reviewed, and the course piloted, prior to release.