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End-of-life care ‘improving’

But round-the-clock palliative care services come in for criticism

Mark Gould

Thursday, 31 March 2016

There has been "steady progress" in improving the care of dying people according to a new audit of the deaths of over 9,000 patients carried out following the withdrawal of the Liverpool Care Pathway.

Overall, the results show "documented improvements" in:

  • Recognition that patients are dying and that they have received holistic assessments of their care
  • The amount and quality of communication with patients who are able to communicate, and with those identified as important to them
  • Symptom control for the dying person
  • Commitment to education, training, reporting and continuous improvement in caring for dying people

However, the audit reveals that there is room for improvement, particularly in the provision of palliative care services 24-7. The audit also shows how some hospitals did well in many areas but not in others. The majority of hospitals did offer a specialist telephone helpline at all times and 53 of 142 hospital sites offered face-to-face palliative care on Monday to Sunday between 9am to 5pm. But for 26 trusts there was no record of face-to-face specialist palliative care involving doctors at any time.

The audit, carried out by the Royal College of Physicians was funded by NHS England and Marie Curie, and commissioned by the Healthcare Quality Improvement Partnership (HQIP). It is the first to be carried out following the official withdrawal of the Liverpool Care Pathway (LCP) in 2014, although some hospitals had already started to replace the LCP with local policies before the previous audit in 2013. 

The new audit revealed:

  • 93% of patients whose death was predictable had documentation that they would probably die (87% in 2013) and in 76% of cases a senior doctor was involved in the recognition of dying.
  • It was recorded that nominated person(s) important to 80% of patients had opportunities to discuss the patient’s condition with a senior healthcare professional but the discussions were not always recorded.
  • 54% of case records showed that the needs of persons important to the patient were asked about, a significant improvement since the 25% result from 2013. Of these, 62% had specific needs identified.
  • In 38% of cases there was documented evidence in the last episode of care that the patient’s needs had been discussed with the people important to them.
  • Excluding the cases of sudden or unexpected deaths, in 84% of cases the people important to the dying patient were notified of the imminent death. Out of those notified, 63% were recorded as being present at the time of death. There was documented evidence of care and support of the patient’s family at the time of and immediately after death in 65% of cases, but with wide variance between different sites.

Claire Henry, chief executive of the National Council for Palliative Care, said: “This report shows how things have improved, but also that there are still unacceptable variations in the care people receive in their final days and hours. We are glad there has been improvement in key areas, and the welcome the call for further ongoing development and training for staff."

Emeritus Professor Sam Ahmedzai, chair of the RCP End of Life Care Audit steering group, said: "The period 2013 to 2015 saw momentous changes in how we look after dying people in England. These include the phasing out of the ‘one-size-fits-all’ Liverpool Care Pathway and the introduction of individualised care, with an emphasis on assessing holistic needs, respecting the wishes of dying people and those important to them, including maintaining hydration where desirable."

"It is heartening that the results of the latest audit largely reflect these changes positively in terms of improved statistics of care for people in the last days of life who were dying in the month of May 2015 in English hospitals. There is still room for improvement, notably in providing 24/7 access to specialist palliative care for those with difficult problems. Our findings also show where some trusts need to improve in some areas, up the level of others to provide consistently high quality care for the dying."

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