The SPICT can support clinical judgment by multidisciplinary teams when identifying patients at risk of deteriorating and dying. It helped identify patients with multiple unmet needs who would benefit from earlier, holistic needs assessment, a review of care goals, and anticipatory care planning.
Background Systematic identification of patients with advanced illnesses is central to UK end-of-life policies. Recognising a limited prognosis fosters decision-making about future care but probabilistic predictions such as the ‘surprise question’ tend to be overoptimistic. Even in cancer, complex mathematical models are only 60% accurate and open to confounders. The 2009 Supportive and Palliative Indicators Tool (SPICT) used clinical indicators derived from a review of prognostic tools to identify patients likely to have advanced illness and unmet supportive and palliative care needs for assessment. Aims To pilot the SPICT tool in the renal, liver, cardiac and respiratory wards of a large teaching hospital and assess its utility in an acute hospital setting. Methods Each ward team developed a customised checklist containing the SPICT clinical indicators. All unplanned admissions to each ward over 2 months were screened and followed up for 3 months to record re-admissions; hospital bed days; time, cause and place of death. The Charleson index of co-morbidities was calculated for comparison. Findings The indicators were evaluated and refined by successive teams. Multi-morbidity predicted a limited prognosis, re-admission risk and complex needs but should take account of disease severity. Most, but not all those who died, had a poor performance status (PS). Patients may spend more time bed-bound when hospitalised so usual status at home is important as an acute deterioration might be reversible. Repeated hospital admissions are well documented but increased community care needs are not always apparent initially. Conclusions The SPICT performs as well as the Charleson index in identifying patients with a limited prognosis and complex needs. The revised version contains fewer, clearly identifiable indicators that provide a rationale for reviewing care goals with patients and planning care; such as hospital admission, poorly controlled symptoms, increasing dependency and robust descriptors for common illnesses.
Background Patient identification and care planning are central to UK end-of-life policies. For patients on renal replacement therapy, dialysis withdrawal is the main cause of death. Most die in hospital after multiple admissions. Aims An indepth, case study of a 24-bedded general renal ward explored the admission, assessment and discharge planning processes of patients identified after an unplanned admission as having unmet palliative care needs and a limited prognosis. Methods The multi-disciplinary renal team worked with the researcher for two months to generate data from multiple perspectives. Patients were screened with a checklist of indicators for advanced disease. 58 (44%) were identified and followed for 3 months. A purposive sample of five patient – carer – GP triads were interviewed at home, soon after discharge. Patients completed a patient outcome score and staff a semistructured questionnaire. The researcher used the Workplace Culture Critical Analysis Tool for ward observations. Findings Advanced kidney disease is punctuated by unplanned hospital admissions due to complications of treatment or co-morbidities. Death often followed an acute deterioration that triggered dialysis withdrawal. Patients demonstrated fluctuating ambivalence about their illness and the future, using avoidance and disavowal to maintain hope. Professionals strived to balance patient wishes with ethical decisions about treatment. ‘Palliative care’ had negative connotations and advance ‘planning for dying’ was not a helpful construct. Conclusions Patients receiving renal replacement therapy focus on short-term goals as they try to ‘live well’ with complex illnesses and treatment. Clinical indicators can be used to identify advanced kidney disease, but prognosis and likely mode of death are uncertain. Anticipatory care planning needs to engage patients and carers in ‘planning for uncertainty’ and could consider levels of intervention for the next acute episode. Making a planned transition to end-of-life care before the patient is dying can be complex and challenging.
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