Over time, end of life care has been heavily influenced by the systems of religion, ethics and spirituality. The Sikh religion was started by Guru Nanak Dev Ji in 1469. It has a unique philosophical understanding of life, death and God which can be relevant to commonly encountered clinical scenarios. Concepts such as ‘Ik-Oankar’, Hukam (God’s will), ego and karma all influence how practising Sikhs respond to situations in everyday life. Understanding the spiritual underpinnings of the Sikh religion is therefore important for clinicians caring for this group of patients. This article will explore the fundamental concepts of the Sikh religion and how these apply to common scenarios encountered within palliative care.

Sikh healthcare professionals make up a small but significant proportion of the workforce in the United Kingdom. The COVID-19 pandemic has presented healthcare staff across the country with challenges relating to safe clinical practice whilst wearing personal protective equipment (PPE). Practising Sikhs are mandated to keep their hair unshorn and have been negatively impacted by some standard PPE requirements. This article aims to raise awareness of this issue and provide suggestions on how this conflict can be resolved.

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BackgroundJunior doctors are often the first to assess deteriorating patients out of hours. From our experience, many deteriorating patients do not have escalation plans in place from the patient's regular medical team. Making decisions to escalate or palliate unwell patients is therefore made more challenging.ObjectivesThe primary objectives of this audit were to identify:1) If deteriorating patients are recognised by nursing staff on the wards2) If these patients are assessed promptly and by the appropriate professional3) If escalation plans exist to guide on call doctors when making management plans for these patients.MethodsData was retrospectively collected using a modified audit tool based on NICE 50 (Acutely ill patients in hospital). Patients at risk of deterioration were identified by an Early Warning Score >5. Thirty case notes were examined on several medical wards in Airedale General Hospital.ResultsA doctor or member of the Outreach Team was contacted in 70% of cases when a patient had a high EWS >5 (standard 100%). A third of patients were not reviewed after a high EWS (standard 100%). Only 5 out of 30 patients had a clear escalation plan highlighting whether higher level care was appropriate. Evidence of preventable harm was not found but examples of poor practice were identified e.g. patients with palliative conditions in whom DNACPR had not been considered.DiscussionThe results were presented orally to clinical staff and in the hospital newsletter to raise awareness of the need to make improvements. A distinctive Escalation Plan form and sticker was designed and is being piloted on the medical wards to encourage 'Day' teams to state a ceiling of care. Feedback will be obtained from staff when re-audit takes place.ConclusionAssessment and management of deteriorating patients must be improved. With the above interventions we hope to show that this can be achieved in the DGH setting.

Background The provision of palliative care is increasing, with many people dying in community-based settings. It is essential that communication is effective if and when patients transition from hospice to community palliative care. Past research has indicated that communication issues are prevalent during hospital discharges, but little is known about hospice discharges. Methods An explanatory sequential mixed methods study consisting of a retrospective review of hospice discharge letters, followed by hospice focus groups, to explore patterns in communication of palliative care needs of discharged patients and describe why these patients were being discharged. Discharge letters were extracted for key content information using a standardised form. Letters were then examined for language patterns using a linguistic methodology termed corpus linguistics. Thematic analysis was used to analyse the focus group transcripts. Findings were triangulated to develop an explanatory understanding of discharge communication from hospice care. Results We sampled 250 discharge letters from five UK hospices whereby patients had been discharged to primary care. Twenty-five staff took part in focus groups. The main reasons for discharge extracted from the letters were symptoms “managed/resolved” (75.2%), and/or the “patient wishes to die/for care at home” (37.2%). Most patients had some form of physical needs documented on the letters (98.4%) but spiritual needs were rarely documented (2.4%). Psychological/emotional needs and social needs were documented in 46.4 and 35.6% of letters respectively. There was sometimes ambiguity in “who” will be following up “what” in the discharge letters, and whether described patients’ needs were resolved or ongoing for managing in the community setting. The extent to which patients received a copy of their discharge letter varied. Focus groups conveyed a lack of consensus on what constitutes “complexity” and “complex pain”. Conclusions The content and structure of discharge letters varied between hospices, although generally focused on physical needs. Our study provides insights into patterns associated with those discharged from hospice, and how policy and guidance in this area may be improved, such as greater consistency of sharing letters with patients. A patient-centred set of hospice-specific discharge letter principles could help improve future practice.

Undiagnosed and underlying medical co-morbidities are known to have a role in the causation of or contribution to injuries sustained in cases of polytrauma. Syncope provoked by valvular heart disease is one such example. Thorough clinical assessment is needed to ensure such diagnoses are detected and treated, whilst ensuring a patient’s ongoing rehabilitation needs are met. Here, the authors report a case of polytrauma, most likely secondary to severe aortic stenosis, causing syncope which was diagnosed at a later stage due to ongoing symptomatology. Delay in picking up such diagnoses can contribute to mortality in these patients or affect morbidity by having a detrimental impact on a patient’s functional recovery.

Introduction In 2012, 22 new major trauma centres were introduced in England. This followed evidence demonstrating that such units saved lives and reduced serious disability. Traumatic central cord syndrome is an example of spinal injury seen in major trauma centres. This condition occurs most frequently as a result of hyperextension to the neck in the presence of spondylosis or degenerative changes. These patients may suffer additional injuries during the initial trauma which may be missed, either due to lack of clinically apparent symptoms or due to the masking of symptoms as a result of neurological compromise.Case presentation We describe a case of a 56-year-old gentleman who sustained a traumatic central cord syndrome following a fall down a flight of stairs whilst disembarking an aeroplane. Following transfer from the major trauma centre to the regional spinal injuries centre it was discovered that he had bilateral radial head fractures which had been missed on the initial primary and secondary surveys. Discussion Radial head fractures are a significant injury in the context of traumatic central cord syndrome due to the potential impact on functional recovery and rehabilitation. The tertiary survey has been proposed as a method to detect subclinical injuries in trauma cases. This case highlights the importance of conducting the tertiary survey to avoid missing important subclinical injuries.