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

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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

helenmeehan@nhs.net

Rachel Davis – senior specialist nurse palliative care

racheldavis1@nhs.net

Tel: 01225 825567