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Care of the dying must improve

Survey finds unacceptable variation in quality and provision of services for dying patients

Mark Gould

Thursday, 15 May 2014

A new audit* by the Royal College of Physicians and Marie Curie Cancer Care has found "significant" variations in the care of people dying in hospitals across England. Communication with patients and relatives was found to be "particularly poor".

The survey accepts that while every patient has different needs, and some will need more pain relief than others for example, there should be no variation in the quality and provision of services, or training in the care of people dying in hospitals.  

If found that only 21% of hospitals had access to face-to-face palliative care services, 7 days per week, despite a longstanding national recommendation that this be provided. Most (73%) provided face-to-face services on weekdays only.

Mandatory training in care of the dying was only required for doctors in 19% of Trusts and for nurses in 28%, despite national recommendations that this be provided. 82% of Trusts had provided some form of training in care of the dying in the previous year; 18% had not provided any.

For most patients (87%), healthcare professionals had recognised that they were in the last days of life, but had only told less than half (46%) of patients capable of discussing this.    

Some 59% of patients were clinically assessed to see if they needed artificial hydration, but discussions with the patient was only recorded with 17% of patients capable of having the conversation. The situation was discussed with more than twice as many relatives and friends (36%).

While previous audits had been based on the goals of care within the now defunct Liverpool Care Pathway for the Dying Patient (LCP), the new audit sampled the care of dying people in hospital, regardless of whether they were supported by the LCP or other care pathways or frameworks, and included more hospitals than the previous audits. The questions were also changed from previous audits to reflect the recommendations of the Neuberger Review of the Liverpool Care Pathway. 

The new audit assessed a sample of case notes of the 6,580 people who died in 149 hospitals in England in May last year and the results from questionnaires completed by 858 bereaved relatives or friends, asking about the treatment of their relative, their involvement in decision making, and the support available to them. It also examined the organisation of care including availability of palliative care services, numbers of staff, training, and responsibilities for care.

The report makes 10 key recommendations including a call for hospitals to provide a face-to-face specialist palliative care service from at least 9am to 5pm, seven days per week, to support the care of dying patients and their families, carers or advocates.

It also calls for education and training in care of the dying to become mandatory for all staff caring for dying patients. This should include communication skills training and skills for supporting families and those close to dying patients

Dr Kevin Stewart, who chaired the audit steering group and is clinical director of the RCP’s Clinical Effectiveness and Evaluation Unit (CEEU) said that although some aspects of care are good he was "deeply concerned" that some hospitals are falling short of the excellent care that should be provided to both dying people and those important to them.

"In particular, communication with patients and their families is generally poor. It is disappointing that hospitals don't seem to recognise this as an important issue, not just for those experiencing this in their own lives, but for the wider public. Everyone wants to know that if they are in the same situation, their needs and those of their families, friends and those important to them will be met, with clinically appropriate treatment, sensitivity and compassion."

* Royal College of Physicians and Marie Curie Cancer Care. National care of the dying audit for hospitals, England. National report. May 2014

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