Objectives Advance care planning (ACP) can help patients with a terminal illness to prepare for the end of their lives. This report describes a regional service improvement initiative to increase the identification of hospital inpatients at this stage in their illnesses and to increase the number of such patients who are offered the opportunity to start the process of ACP. Methods Data were collected prospectively over a 7 month period from four acute hospital trusts and a specialist cancer centre in the South-West London region. Each unit identified a specific patient population who were screened for eligibility to engage in the process of ACP. Data concerning the reasons for eligibility, the suitability for discussion and the various reasons why patients did not complete the process, were recorded. Results Over a 7 month period 1980 patients were screened and 559 (28.2%) were found to be potentially eligible for an ACP discussion. Of these 227/559 (40.6%) were deemed suitable for a discussion by medical staff. The majority of these patients (195/227; 86%) were offered the opportunity to undergo ACP discussions and 144/ 195 (73.8%) agreed to begin the process of ACP. Conclusions This report shows that a targeted approach can result in increased uptake in the number of patients who engage in ACP. However, systematic identification of potentially eligible patients requires a significant investment of clinical time and resources. BACKGROUNDAdvance care planning (ACP) is a voluntary process that enables an individual who has the capacity to anticipate how their condition may affect them make decisions, and choices about their future care, and communicate them so that they
We select the letters for these pages from the rapid responses posted on bmj.com favouring those received within five days of publication of the article to which they refer. Letters are thus an early selection of rapid responses on a particular topic. Readers should consult the website for the full list of responses and any authors' replies, which usually arrive after our selection. mark thomas Continuous deep sedation Please, don't forget ethical responsibilities Alastair Bint general practitioner, st luke's surgery,
Background The End-of-Life Care (EoLC) Strategy 2008 highlighted the importance of early identification of potential for dying and Advanced Care Planning (ACP).1 2 3 Early awareness of poor prognosis helps patients and their relatives to understand their illness and make informed choices about their care; for instance whether to decline aggressive intervention and hospitalisation if it is unlikely to improve their quality of life. Aims and Objectives To prompt early communication within the MDT and with patients and their relatives about ACP for those deemed to be in their last year of life. Method Data from 40 discharged patients, who had been identified as likely being in their last year of life, was collected in each audit cycle.Cycle 1 was a retrospective case notes analysis from one Care-of-the-Eldery (CoE) ward. Five key areas of ACP were reviewed: resuscitation status, prognosis, ceiling of care, readmission plans, patient/family awareness of condition and prognosis.Prior to cycle 2, an ACP Summary proforma was implemented where discussions around the five key areas could be summarised. It was introduced at a CoE department meeting and teaching sessions were held for junior doctors.Results Tables 1 and 2 illustrate our findings.
Background and aims Studies support that the majority of patients want to die at home, yet in London, 66% die in hospital and Nationally, only 35% die in their home/care home. We therefore audited referrals to the hospital palliative care team over a period of 6 months, looking at documentation of and outcomes for preferred place of care/death (PPoC / D). Reasons why preferences were not achieved were documented using a locally adapted version of a model devised by the Health Sciences Research Institute, University of Warwick to measure the constraints to enabling patients to die at their preferred place (Munday et al 2009). Results 83% of patients had a record of PPoC/D. 79% of patients who expressed a preference achieved this. Unpredictability of illness/rapid deterioration and lack of recognition of the potential for dying, were the main barriers that prevented patients achieving their preferences (41% of patients). For the 17% of patients where there was no record of PPoC/D, 45% was due to cognitive impairment and 31% due to rapid and unexpected deterioration. For patients where rapid and unexpected deterioration was the main factor to not recording/not achieving PPoC/D, discussions had not taken place prior to admission in the acute illness. Conclusion Better identification of the potential for dying through the use of models such as the Gold Standard Framework in acute hospital's, might reduce barriers to achieving PPoC/D. Conversations about the future and about preferences can be initiated once the potential for dying is recognised. There is also a wider societal need to encourage more open discussion of these difficult issues and thereby address the taboos that surround attitudes towards death and dying to support decision making at the end of life.
BackgroundNICE organ donation guidance makes it explicit in its first recommendation that ‘organ donation should be considered as a usual part of “end-of-life care” planning.’ The Liverpool Care Pathway (LCP) incorporated a prompt for clinicians to discuss tissue and organ donation with the patient, and if appropriate their relatives. A recent audit found that of 20 Kingston Hospital LCP proformas completed, only 1 had documented that this information had been ascertained.AimsTo explore junior doctors' attitudes surrounding discussion of tissue donation in the context of end of life care.MethodsWe surveyed 33 junior doctors about their knowledge and attitudes towards tissue donation and end of life care, seeking to elucidate why the proforma question- “Does the patient have an expressed wish for tissue donation” was not being asked.ResultsFifty-two percent were not aware that there was a question about expressed wishes for tissue donation. Common reasons for not completing the question on the proforma included: “timing not feeling appropriate”, “lack of familiarity with tissue donation procedure” and "unsure if patients on the LCP will be suitable". Views on the most appropriate time to discuss tissue donation were mixed: 45% said “A&E registration” and 42% “as part of end of life discussions”. Only 56% of junior doctors reported having received any training on tissue donation.ConclusionsJunior doctors are undertrained and not comfortable discussing tissue donation as part of providing end of life care. Knowledge and communication skills pertaining to tissue donation should be incorporated into the foundation doctors' curriculum. Locally we plan to guarantee the implementation of teaching for all doctors about tissue donation and to add comprehensive information about the subject, including eligibility criteria and contact details for further guidance and support to the Kingston Hospital “junior doctor handbook”.
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