Let’s get the Conversation Started
Helen Meehan - Lead Nurse Palliative and End of Life Care
Rachel Davis - Senior Clinical Nurse Specialist Palliative Care
Background
Royal United Hospital (RUH) –
catchment population of 500,000
565 beds
Serves 4 CCGs
Hospital integrated specialist palliative
care and end of life care (EOLC) team
Specialist palliative medical sessions
and out of hours advice from Dorothy
House Hospice
EOLC working Group
Chaired by Helen Blanchard Director of
Nursing
EOLC working group meets quarterly
Oversees annual work plan for EOLC –
now aligned to Ambitions for 2016/17
Supports service improvement in EOLC
including the Conversation Project
Annual Report to Quality Board,
Management Board and Trust Board
Why focus on conversations? Caring for people nearing the end of life is one of the most important things
we do in hospitals
78% of people that died in England had at least one admission to
hospital in their last year of life1
A third of all hospital admissions in last year of life occur in the last 30
days before death1
Although deaths in hospital nationally have reduced, most people still die
in hospital (>1500 deaths in the RUH each year)
People who have engaged in Advance Care Planning (ACP) are less likely
to die in hospital2 1. National end of life care Intelligence May 2012
2. National Council for Palliative Care 2015
Talking with our members and staff
Trust staff (doctors, registered nurses and AHPs) invited
to complete a questionnaire to share information on the
challenges of having conversations about end of life
care and what we could do better
32 Questionnaires completed
Trust members (patients, families and public) invited to
participate in telephone interviews to support a greater
understanding of what helped and what was challenging
when talking about end of life care
21 Interviews completed
Feedback from staff questionnaire
What can we do better? What are the challenges?
Feedback from talking with Trust members
What was important to you? What was difficult?
Let’s Get Talking - The Conversation Project
Initially developed from partnership with the Kings Fund and Health
Foundation PFCC in 2013/14. Project facilitated by the specialist
palliative care (SPC) team, working with 3 wards
Continued development and rollout was supported by the SPC
team through a CQUIN in 2014/15 on 9 wards
Developed for Dementia and Frailty as part of a Health Education
Southwest funded project in 2015/16. Collaborative project with
SPC team, consultants in geriatric medicine, dementia coordinators
and Older Persons Unit
Conversation Project – aims
Earlier recognition of end of life/recovery uncertain in acute hospital
setting, for frail elderly patients and patients with dementia
Improving communication and advance care planning for these patients
and their families
Better awareness of the need to improve documentation of conversations
related to end of life care
Improve sharing of information related to ACP on transfer and discharge
of these patients
What did we do? Used PDSA model for service improvement
Established a working group to support the
Conversation Project for dementia and
frailty
Built on resources developed for the
Conversation Project
Supported training for staff in recognition of
end of life care/uncertainty of recovery,
having conversations to support ACP and
using resources
Resources developed
Adopted SPICT and Rockwood assessment tools to support identification of patients with EOLC and frailty
Conversation Project Key Card for staff
ACP information leaflet for patients and families
ACP template
Conversation Project and ACP information poster
Intranet resource for the Conversation project and ACP
Conversation Project – let’s CHAT
Consider: assessment of frailty, what the patient and MDT tell us,
prognostic indicators
Have conversations: within the MDT share observations and recognition
of approaching end of life, listen to the patient and ask ‘what matters
most,’ have conversations with those important to the patient ‘hoping for
the best whilst preparing for the worst,’ acknowledge uncertainty of
recovery/future
Advise the MDT: does the ward team know and understand the
patient’s wishes, document conversations and what is important to the
patient and the family
Transfer of information and improve continuity of care: telephone the
GP, DN or care home manager, ensure discharge documentation
includes summary of discussions had, decisions made and advice about
ACP
C
H
A
T
What did we find? 50 sets of patient notes audited through quarter 2-4
64% (n32) had problems associated with dementia and frailty
78% (n39) admitted to hospital from home and 20% (n10) from a care home
46% (n23) patients lacked capacity to be involved in ACP discussions
94% (n47) evidence of discussion with the patient’s family/carer
1 patient had a Lasting Power of Attorney for Health and Welfare
None of the patients had a community ACP or ADRT on admission
None of the patients had a ‘This is Me’ document on admission
46% (n23) of the patients died during admission
54% (n27) of the patients were discharged
Evidence of conversations in MDT records
• Evidence of
discussions with the
patient and/or
recorded reasons
why not appropriate
and discussions with
those important to the
patient
• Evidence of content
of the discussions
Outcomes for national EOLC audit
Clinical outcome
indicators from the
national EOLC
audit – dying in
hospital 2015/16
• Evidence of
improved
communication/
discussions
relating to EOLC
• Clinical indicators
for communication
above national
average
What has been achieved
Earlier identification of approaching end of life and that this is
included as part of the MDT/white board meetings
Advance care planning is more likely to be part of the normal ward
vocabulary
The conversations, decisions and discussions are more clearly
documented in the medical notes
Information is more regularly communicated to the Primary Health
Care Team in discharge letters
Challenges ahead Developing and maintaining a cultural change in the role of health
professionals in their earlier recognition of end of life care
Maintaining staff engagement and motivation to include this in their
daily work
To educate and support staff in identifying cues and engaging in
what can be difficult and challenging conversations
To embed the Conversation Project principles across all wards
To seek further feedback from patients and families and use this to
improve practice
Future work and next steps To improve the communication both from the community with
admissions and at the point of discharge
To ensure that the decisions and discussions made both in hospital and the community are shared to inform and support care planning
To explore the effect decisions and discussions had in hospital have an impact on advance care planning once the patient is discharged
To promote the Conversation project model and ACP within other hospital areas eg. Outpatients, pulmonary rehabilitation, drop-in sessions for ACP within Older Persons Unit
Conversation Project in summary Conversation Project model has developed
locally
Identification of patients with uncertain recovery/EOLC needs
Promoting conversations to support advance care planning (ACP)
Using information from ACP discussions to inform care planning
Sharing information on ACP as part of discharge planning and transfer of care
Contacts
Helen Meehan – lead nurse palliative care / end of life
Rachel Davis – senior specialist nurse palliative care
Tel: 01225 825567