Nottinghamshire Insight

Joint strategic needs assessment

End of life care for adults (2017, final draft)

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Topic title End of life care for adults (2017, final draft)
Topic owner Nottinghamshire end of Life Strategic Advisory Group
Topic author(s) Zaid Kureeman
Topic quality reviewed Kristina McCormick
Topic endorsed by Nottinghamshire end of Life Strategic Advisory Group
Topic approved by Pending approval by HWIG on 28/9/17
Current version Final draft 7/7/17
Replaces version n/a
Linked JSNA topics

Executive summary

Introduction

Dying is a part of life. For everyone, death is a unique experience which is shaped by many factors; notably an individual’s physical condition, their mental and spiritual well-being, and the care provided to them. A “good death” is not easily defined given subjectivity, however The End of Life Care Strategy (1) defines it as being treated as an individual, with dignity and respect, being free of pain and other symptoms, being in familiar surroundings with your family and friends.

End of Life care aims to offer individuals choice around symptom control, their care and their preferred place of care (PPC) and death. People reaching the end of their life may experience a range of needs. Managing these needs requires a multidisciplinary approach encompassing teams across the health, social and voluntary care sectors. Offering patients care centered on their preferences, psychological, spiritual and social needs is the cornerstone, as is involving family, friends and carers of dying individuals.

The Office for National Statistics (ONS) reported a 5.6% increase in deaths in England and Wales in 2015 - the greatest annual increase for half a century. Whilst these figures are set against a backdrop of a longstanding decrease, January 2017 saw a 21% increase in deaths compared with January 2016 (2). An increasing older and frailer population means more people dying each year, and increasingly complex populations using services.

Of all deaths, three quarters are expected with individuals experiencing an end of life (EOL) phase with a life limiting long term illness (LLLTI) – 530,000 died in 2015 England and Wales, so almost 400,000 could have benefited from EOLC services (3–6). Whilst EOLC is generally well regarded nationally, reports and research frequently identify sub-standard care in the EOLC settings (7–10). The Parliamentary and Health service Ombudsman’s report Dying without dignity (2015) outlined some key themes related to EOL care shortcomings. These included poor recognition of the dying process, poor symptom control, poor communication and inadequate out of hours services (10).

This JSNA will explore what is known about palliative and end of life care (EOLC), which groups of individuals use these services, and what we know about services in Nottinghamshire. Recommendations will be made based upon the findings the JSNA, and offer an insight into overarching issues that act as barriers to good EOLC.

Unmet need and gaps

Service gaps and needs are discussed in-depth in section 8. The key themes supporting the recommendations are:

  • A culture amongst generalist providers that does not always see EOLC as “their business”.
  • Society also still sees EOL as a taboo subject.
  • Clinical staff may fail to recognise dying and/or disease trajectories, and may not always enact good EOLC through ACP and palliative registration (EPaCCS).
  • The use of EPaCCS (electronic palliative care co-ordination service) is very variable amongst GPs, with improvements in particular surgeries required to embed its use of as a cultural norm in the community setting.
  • There is also a lack of use in hospital settings and other services. Hospitals would benefit greatly from routine access to EPaCCS as many EOLC discussions and plans are made when EOL patients deteriorate and require admission to hospital. EPaCCS in hospital would alleviate some pressure from community EOLC providers, but also encourage a positive culture amongst hospital doctors regarding EOLC.
  • Finally, there are many barriers to achieving death in an individual’s PPC. Barriers to achieving a death at home include:
    • A lack of understanding amongst family/carers of EOL/dying individuals,
    • Gaps in services e.g. night sitter availability and bed based specialist care.
    • Gaps in EOL education

Unequal access to EOL/palliative services which currently see a mismatch in service need and use amongst older patients, and those with non-cancer diagnoses.

Recommendations for consideration by commissioners

Holistic and effective care

1

End of Life care is everybody’s business and this responsibility is explicit in every contract, especially in relation to older people

2

Encourage a culture among all healthcare professionals to discuss EOL openly, and recognise EOL as their business

3

Improve the ratio of referrals to specialist palliative care for patients with dementia/non-cancer diagnoses through improved inter-disciplinary working and medical education. (see also recommendation 6 below)

4

Each person recognised to be in EOL has a named responsible clinician, and a named care coordinator as a first point of contact

5

Health and Wellbeing board to consider enabling choice, better coordinated care and integrated models of EOLC in making strategic plans

6

Conduct qualitative studies/obtain user feedback/outcomes measures for the bereaved and dying

Better information sharing

7

EPaCCS is made accessible to health and social care providers involved with patients in EOL (particularly hospital wards, acute services, GPs)

8

Improved data collection through EPaCCS to identify rates of access for older people, people with dementia, BME and LGBT populations, and therefore identify populations requiring intervention.

9

Participate in the development of GSF EOLC measures to be used by all localities to improve EOLC benchmarking, and improve EPaCCS data collection and interrogation (e.g. primary life-limiting diagnosis, contributing co-morbidities).

10

Continued improvements of diagnosis rates and use of ACP (through EPaCCS) for dementia patients – using EPaCCS data interrogation as appropriate

11

Adopt the ReSPECT tool in hospitals and the community to improve ACP amongst health care professionals (see also recommendation 13 below)

Education and Training

12

Improve generalist palliative care quality – further update training is mandatory for healthcare professionals (a) recognising dying, ACPs, (b) meeting needs - understanding of local services). Existing training for foundation doctors continues.

13

Promote care staff training schemes, particularly domiciliary care (such as GSF/LOROS training programme). Consider whether providers could access health funding for this.

14

Promote education/positive EOLC culture through introduction of ReSPECT tool

15

Encourage compassionate communities though strategies as mentioned through understanding public perception, engaging people in commissioning, encourage wider public engagement informing community development and working with health/social care professionals in community development and engagement

References

  1. End of Life Care Strategy [Internet]. Dying Matters. 2011 [cited 2017 Apr 24]. Available from: http://www.dyingmatters.org/page/end-life-care-strategy
  2. Deaths registered in England and Wales (Series DR) - Office for National Statistics [Internet]. [cited 2017 Feb 19]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredinenglandandwalesseriesdr/2015
  3. Identifying end of life patients [Internet]. Dying Matters. 2011 [cited 2017 Apr 24]. Available from: http://www.dyingmatters.org/gp_page/identifying-end-life-patients
  4. Dementia statistics | Alzheimer’s Disease International [Internet]. [cited 2017 Apr 24]. Available from: https://www.alz.co.uk/research/statistics
  5. Predicting Death: Estimating the proportion of deaths that are ‘unexpected’ [Internet]. [cited 2017 Apr 27]. Available from: http://www.endoflifecare-intelligence.org.uk/resources/publications/predicting_death
  6. Janet Shucksmith, Vicki Whittake, Sarit Carlebach. Dying: Discussing and planning for end of life. Br Soc Attitudes [Internet]. (30). Available from: http://www.dyingmatters.org/sites/default/files/BSA30_Full_Report.pdf
  7. Independent review of the Liverpool Care Pathway. More Care, Less Pathway. A Review of the Liverpool Care Pathway. 2013.
  8. The Choice in End of Life Care, Programme Board. What’s important to me. A Review of Choice in End of Life Care. 2015.
  9. End of Life Care. Fifth Report of Session 2014–15. London: The Stationery Office Limited: House of Commons Health Committee; 2015.
  10. Dying without dignity | Parliamentary and Health Service Ombudsman (PHSO) [Internet]. [cited 2017 Feb 19]. Available from: http://www.ombudsman.org.uk/

Key contacts

Author: Dr. M Zaid Kureeman, email: muhammad.kureeman@nhs.net

Senior Public Health and Commissioning Manager: Gill Oliver, email gill.oliver@nottscc.gov.uk

This is an online synopsis of the topic which shows the executive summary and key contacts sections. To view the full document, please download it.

Full report »