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Sharing Current Scottish Practice

Poster abstracts of the month

The SPPC Annual Conference in 2017 featured 46 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 eight of these:


Culture Sharing: Death and dying in North India – learning from a mentorship visit to a rural palliative care team in North India


Kim Donaldson; Lorraine Wilson

Harriet Benson Memorial Hospital (HBMH) is part of the Emmanuel Hospital Association (EHA), a charitable organisation delivering healthcare in rural North India. HBMH provides general, obstetric, public health and palliative care services to people in and around the Lalitpur district, Utter Pradesh. Following an evaluative report1 of the Lalitpur palliative care services, the Community Palliative Care Team Lead and Practice Development Facilitator from St Columba’s Hospice visited to offer support and mentorship palliative care team. Adopting a positive enquiry approach many areas of extraordinary practice were identified along with areas of practice for potential development beyond the scope of the Hospice UK (2009) toolkit2 for resource limited areas. The main areas for development included deepening understanding of pain assessment and management; identification of depression and clinical record keeping. The learning was by no means one sided, the acceptance of death as part of living was evident with nothing hidden has left us asking the question – can we say the same?

1 Haraldsdottir, E. and Mundy, D. 2015. Evaluation of the EHA Palliative Care Project Funded by EMMS International. Edinburgh.

2 Help the Hospices (Now Hospice UK). Palliative Care Tool Kit. Help the Hospices: London

Discontinuing non-essential interventions at the end of life – a split site, dual discipline quality improvement project


Dr Alana Brown-Kerr; Dr Lorna Frame; Dr Victoria Beveridge; Dr Sarah Bowers; Sr Julie Carroll; Sr Fiona Kerr; Dr Claire Borland; Dr Lauren Anderson; Dr Alistair McKeown; Dr Fiona Finlay.

Background/ Aim: Local, National and Scottish Government guidance advocates discontinuing burdensome interventions when caring for patients at the end of life. In two large Scottish hospitals, over 70% of patients identified to be dying underwent blood tests and National Early Warning Score (NEWS) monitoring within 24 hours of death. The aim was to reduce this figure by 50%.

Methods: Data were collected over 6 months in 9 wards across 2 hospital sites. PDSA methodology was used and the following tests of change undertaken; 1. Stickers stating “No further blood tests/NEWS monitoring” placed in medical/nursing notes 2. Joint medical and nursing education about optimising care at end of life 3. An “alert” incorporated into electronic case records to prevent requesting of blood tests.

Results: Initial analysis demonstrates a downward trend in unnecessary investigations/monitoring in the 24 hours before death. The full project will be analysed by early September.

Conclusion: This multi-disciplinary, multi-site quality improvement project demonstrated that a combined programme of medical and nursing education, with visual and electronic prompts can reduce the proportion of patients undergoing investigations in the last day of life, as well as increasing the confidence and skills of the MDT in caring for dying people.

Do Hospital Anticipatory Care Plans improve patient care? An evaluation of end of life care in a District General Hospital


Dr Alice Radley; Dr Heather Osbourne; Dr Tahlia McKenzie

Background: Hospital Anticipatory Care Plans (HACPs) are a clinical tool used to communicate end of life care decisions. This study evaluated delivery of patient care at the end of life with and without a HACP in place.

Method: All deaths in Hairmyres Hospital between 02/02/16-02/02/17 were reviewed using scanned case notes in Clinical Portal. All expected deaths were included in the study. Patients were categorised according to presence or absence of HACP at the time of death. The following aspects of end of life care were evaluated: treatment escalation decisions, DNACPR decisions, DNACPR discussions, referral to hospital palliative care services and consideration of patient’s preferred place of care. Descriptive statistics and significance testing were used to compare outcomes between HACP and no HACP groups.

Results: 1115 deaths occurred within the study period. 913 cases met the criteria for expected deaths.

Presence of a HACP predicted greater frequency of documented treatment escalation decisions (p<0.002); greater number of documented DNACPR decisions (p=0.002); more frequent DNACPR discussions with the patient’s family or next of kin (p=0.003); and a greater number of referrals to hospital Palliative Care services (p=0.00007).

Conclusions: HACPs are valuable clinical tools which can improve patient care at the end of life.

Do cloth bereavement bags make a difference when handing back patients’ belongings to bereaved relatives/ carers compared to the current plastic bags within the acute hospitals across NHS Greater Glasgow and Clyde?


Sharon Lambie

When a patient dies within NHS Greater Glasgow and Clyde (GG&C), belongings are currently returned in a plastic bag which can often seem undignified and disrespectful when handing these back to a loved one. These bags are universally used for all belongings, meaning that there is no recognition for someone who has been bereaved. An audit was undertaken to see whether there was a quality improvement with handing over patient's belongings in a cloth bereavement bag compared to a plastic bag. Included in the audit was returning patient's jewellery in a small organza bag and a condolence card was attached to the cloth bag using a ribbon. The audit showed very positive results from both staff and relatives experience concluding that it showed that belongings were handed back in a much more caring way with greater respect, dignity and compassion. Funding has now been granted to roll out the cloth bereavement bags in all areas across GG&C.

End of life care in hospital - are we getting it right?


Elizabeth Moss; Dr Fiona McFatter

We present the results of an audit of End of Life Care in Ninewells Hospital which was undertaken as a 4th year medical student project.

In 2014 the Scottish Government published guidance on 'Caring for people in the last days and hours of life'. This guidance is applicable in all care settings. As the majority of deaths occur in hospital it is essential that good end of life care is provided in this setting. A retrospective case note audit was undertaken of 50 patients who died between Jan-March 2017. A convenience sample from all deaths in that period was taken according to case notes which were available. The care provided was compared to the 4 Principles outlined in the Scottish Government Guidance. We found evidence of good end of life care. This included - in over 90% of cases there was documented end of life care discussion with patients or families, DNACPR forms had been completed and anticipatory medication was prescribed. There was direct hospital palliative care team input for only 5 patients. This suggests good end of life care was provided by a range of hospital specialties supported by existing skills in caring for people who are dying.

End of life care: service evaluation in a hospice in-patient unit


Amanda Powell; Gill Foster

Scottish Government guidance supports clinical and care staff planning and providing care during the last days and hours of life. A service evaluation was undertaken to establish whether care provision in a hospice in-patient unit encompassed its four key principles.

Thirty consecutive case-notes of patients who died in the in-patient unit were reviewed retrospectively for evidence of documentation of such care.

60% of patients had informative, sensitive and timely discussions about dying including their concerns, goals, wishes, and psycho-social and spiritual needs. 83% of those who didn’t had cognitive impairment or were unconscious.

97% of case-notes had documentation that death was expected, inappropriate interventions discontinued (97%), inappropriate drugs discontinued (93%) and anticipatory medication prescribed (100%).

DNACPR decision was discussed with 96% of patients without cognitive impairment. All patients with cognitive impairment had that decision discussed with a relative/carer.

100% of case-notes documented informative, timely communication with relatives/carers and advice regarding bereavement support and in 97% that practical advice was given after death.

A further study is planned to ascertain from clinical staff factors that prevent or facilitate exploration and documentation of the holistic needs of those with cognitive impairment.

End-stage chronic liver disease: a look at the last year of life


Ruth Yates; Eliana Saffouri; Fiona Finlay; Alix Morieux

Background: Patients with chronic liver disease (CLD) and its complications present frequently to hospital; at end-stage, supportive and palliative care needs can be high. In this study, the last year of CLD patients' lives is described to seek opportunities for earlier concurrent palliative care involvement.

Methods: A comprehensive retrospective case-note analysis was performed of patients who died of CLD (or complications) in a teaching hospital over a year (n=77).

Results: Alcohol was the aetiological factor in 84.4% of cases. Median survival from diagnosis to death was 2 years. A third of patients died on their first admission to hospital. Only 15 patients (19.5%) were referred to the Hospital Specialist Palliative Care Team (HSPCT). Many patients had investigations within 24 hours of death. The majority of patients (89.6%) had a DNACPR order in place at death but 38% were signed less than 24 hours before death.

Discussion: Despite evidence that patients with CLD have a poor prognosis, high symptom burden and supportive needs, only a small minority were referred to the HSPCT. This data highlights the need for greater collaboration between specialties to both help patients live as well as possible while preparing them for the reality of a poor prognosis.

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