Adult Palliative And End Of Life Care Strategy
Adult Palliative and Endof Life Care Strategy2016 - 2019#PROUD TO CARE FOR YOUwuth.nhs.uk
shareddocumentationandITInterface with the wider community – WirralEnd of Life Care Charter, Dying Matters, Schwarzrounds for staffAdopt a system-wide perspective to serviceimprovement – active collaboration withcommunity and hospice services, dashboard toinform service development need and innovationDevelop more integrated relationships withother specialtiesDevelop the MDT base within the specialist teamDevote time to team-buildingStandardisesystemsCo-ordinate and plan care more effectivelyby working more collaboratively andprioritising integrationObjective No.3wuth.nhs.uk@wuthnhsLocal and national audit enabled via Millennium / Develop End of Life Dashboard to inform service monitoring and developmentRelaunch service / Develop business case for additional staff / Service level agreement with Wirral Community TrustReview governance structure / Revise and improve use of risk register / share learning from compliments and complaintsDevelop new models of care / Healthy Wirral – registries / Research / Advancing Quality improvement methodologyTraining needs assessment and session development / CNS-led CPD programme / Build end of life facilitator and link nurse rolePromote PROUD values / Everybody’s responsibility / Dialogue – Dying Matters / Schwartz rounds#PROUD TO CARE FOR surementDevelop a culture of ‘information for action’linked to clear clinical governance structures –national and local audit, strengthened incidentreview process, policy oversight, outcomesdashboard, patient feedback and clinicalincident reportingGrow the knowledge, skills and capabilitiesof the hospital palliative and end of life carespecialist team – shared skills and learningprogramme, special interest areasEmbed recognised quality frameworks –TRANSFORM high impact enablers, 5 Prioritiesof care (Wirral multidisciplinary Record care foradults last days of life), NICE Quality standards,North West End of Life Care Model ImplementNICE Quality StandardsUnderstand and meet the training needsof clinical and non-clinical WUTH staff andvolunteers – training needs assessment, focuson sensitive and timely communication, newtools and processes, holistic assessmentHigh profile relaunch of the service andstrategyInvest in and empower staff toapproach care towards the end of life as‘everybody’s business’Deliver system-wide improvements thatmake the best use of quality frameworksand specialist expertiseConduct a workforce review to build capacityand clinical leadershipObjective No.2Objective No.1Vision: Our ambition is to make palliative and end of life care as good as it can possibly be each and every time. By working togetherwe will provide care that is well planned, compassionate, holistic, and focused on continuously meeting the needs of the individual andthose close to themAdult Palliative and End of Life Care Strategy 2016-19
1. IntroductionSpecialist palliative care helps those with advanced, progressive, incurable illness to live as wellas possible until they die. It enables needs (physical, psychological, social or spiritual) of thepatient and those close to them to be identified and met throughout the last phase of life andinto bereavement.iThis strategy sets our vision of excellence in adult palliative and end of life care –Our ambition is to make palliative and end of life care as good as it can possibly be each andevery time. By working together we will provide care that is well planned, compassionate,holistic, and focused on continuously meeting the needs of the individual and those closeto themWe will concentrate our efforts on three overarching aims, which will deliver big improvementsin the care we can offer, resulting in better experiences for those who are entering the lastyears, months, days and hours of their lives.1. Delivering system-wide improvements that make the best use of quality frameworksand specialist expertise,2. Investing in and empowering staff to approach care towards the end of life as‘everybody’s business’3. Co-ordinating and planning care more effectively by working more collaboratively andprioritising integrationAt the heart of our plans to develop palliative and end of life care are the Trust PROUD values(Patient, Respect, Ownership, Unity, and Dedication) and the NHS 6Cs, Courage, Commitment,Care, Compassion, Competence and Communication. We are clear that delivering the highestquality care means developing a service that is patient-centred, efficient (timely and withoutduplication), effective (evidence-based and safe), equitable (provision is in line with need andaccessible to all), and reliable (a consistently good service for patients, carers and families). Theimprovements introduced by this strategy will support Wirral University Teaching Hospital NHSFoundation Trust’s vision to be,‘the First Choice Healthcare partner to the communities we serve, supporting patients’ needsin an integrated and seamless way: from the home, through to the provision of regionalspecialist services by partnering with other health and social care providers across the public,private and 3rd sectors.’2. ScopeThis strategy has direct and immediate relevance to commissioners and providers of SpecialistPalliative Care and allied services in Wirral; encompassing care which is delivered in hospital,in the community, and at Wirral Hospice St John’s. Linked to this strategy is a separate actionplan and monitoring dashboard, underpinned by clear lines of governance and accountability,including the Trust-wide risk register, and board assurance framework. The ‘strategy on a page’document identifies enabling strategies which are needed to help us realise our vision.3. End of life and palliative care aspirationsThe milestone objectives in this strategy derive from a clear assessment of need, which hasbeen informed by a variety of sources, from national policy and guidance, to inspection, audit,epidemiological data, compliments and complaints. This analysis has helped us to be clear onthe things that are working well in end of life care - the assets that we can build on further, andgaps where action is most needed to bring about change. However, we fully recognise that inorder to achieve the best quality care we need to do more than tackle deficits, so our objectives
also reflect the Trust’s aspirations for the service over the next three years.PopulationIn England and Wales almost 1% of the population dies each year.ii In 2014, 3,548 deathsamongst Wirral residents were registered. 1,443 of these related to adult inpatient deaths atWUTH and a further 601 which occurred post-discharge.iii Equal numbers of deaths were fromcancer, cardiovascular diseases and other causes, with one in seven attributable to respiratorydisease, which is higher than the national average. 69% of deaths were in people aged 75 orolder. Currently, a fifth of the local population is aged 65 or over and 2.5% (around 8,000) are85 or over, with this figure expected to more than double by 2033.ivNational research into people’s preferences regarding place of death suggests that in the NorthWest, as elsewhere the most common answer (64%) is home followed by hospice (26%), witha growing proportion of people in older age groups preferring hospice care (41% in peopleaged 75 or older).v Currently in Wirral, 48% of deaths across all age groups (The large majority(84%) of deaths in hospital are in individuals aged 65 years or older) occur in hospital and23% at home (falling to 15% for people aged 85 or over), which is in line with the picturenationally. Compared to national figures fewer deaths occur in hospice settings (3%), and moretake place in care homes (23%). In Wirral, 65% of people with dementia die in their usual placeof residence and 35% die in hospital, reflecting findings at a national level.viEstablishing a preference for place of death and planning for that is an important aspectof palliative and end of life care. However, patient-centred approaches also recognise thatpreferences can and often do shift as time passes and the needs of the patient and importantothers change. Recent research suggests that ultimately the experience of dying (freedom frompain and distress, privacy and dignity, and the opportunity for those close to the dying personto be present) carries more meaning and value for patients than the location itself.viiThese statistics illustrate some of the current and future challenges that confront palliative andend of life care services. We need to enable more people to die in the setting of their choiceand to improve the quality and experience of hospital care, which will continue as the mainalternative for many. This is especially pressing since we know that 30% of hospital inpatientsare in the last year of life.viiiIn order to make good plans it is essential that people entering the last year or months of lifeare offered the opportunity to participate in advance care planning. This requires sufficientspecialist staff and clinical leaders as well as a bedrock of generalist staff who are confidentand equipped to have the right conversations at the right time and to provide patient-centredend of life care. An organisation that truly recognises end of life care as ‘everybody’s business’can release more expertise to devote to specialist palliative care and complex end of life care.PolicyA wide array of national policy and guidance from a number of expert bodies has been publishedin recent years. The following documents have helped to shape and inform this strategy andwill also guide the implementation and service transformation phase. Relevant local policies,guidelines and standard operating procedures are included in the action plan. Transforming end of life care in acute hospitals - The route to success ‘how to’ guide(revised December 2015)ix Actions for End of Life Care: 2014-16x Ambitions for Palliative and End of Life Care: A national framework for local action2015-2020xi One chance to get it right -Improving people’s experience of care in the last few days
and hours of lifexii NICE quality standards for end of life care for adults (QS13)xiii and guideline for care ofdying adults in the last days of lifexivAt the heart of each of these documents are six overarching ambitions for palliative and endof life carevii, underpinned by five high impact enablers (below). Work has already begun onthe introduction of some of these, with much more still to achieve in some areas, notably theAmber care bundle and advance care planning.National ambitionsPriority enablers1. Each person is seen as an individual;1. Advance care planning2. Each person has fair access to care;3. Maximising comfort and wellbeing;2. Electronic Patient Care Co-ordinationSystems4. Care is coordinated;3. Amber care bundle5. Staff are prepared to care;4. Rapid discharge home6. Communities are prepared to help5. Priorities of Care (One Chance to get itright)The North West End of Life Care Model developed by strategic clinical networks will also beadopted as a local strategic framework. A key strength of this model is the perspective it offerson when palliative and end of life care is appropriate; beginning with diagnosis of life-limitingillness and ending with bereavement support during the year after death. Developing thiscontinuum of changing support will be one of the key changes that this strategy will deliverthrough each of its main objectives.The North West End of Life Care Model1AdvancingDisease1 year/s234IncreasingdeclineLast Daysof LifeFirst DaysAfter DeathMonthsWeeksDeath5Bereavement1 year/sCurrent service structureHospital Specialist Palliative Care TeamThis is a commissioner led integrated service. Wirral University teaching Hospital employsand manages the end of life facilitators and the Consultant contracts are held at WUTH; theSpecialist Palliative Care Nurses in-reach from Wirral Community Trust and are managed byWirral Community Trust. There is no service level agreement between Wirral Community Trustand WUTH. 0.7 sessions delivered by two part time Consultants in Palliative Medicine from a sharedresource across an integrated service. The Consultants provide support to all inpatientsand one outpatient clinic per week. 1.00 wte Band 7 End of life Facilitator (currently flexible part time 0.8wte) 1.00 wte Band 6 End of Life Facilitator (currently part time 0.6 wte) 0.2 wte Band 4 admin support (currently unavailable due to capacity issues)
Named AHP to attend the weekly 90 minute MDT (often unable to attend due tocapacity issues and can only provide minimal additional input) Variable support from the Community Clinical Nurse Specialists (CNS) employed byWirral Community TrustThe Palliative Medicine consultants on Wirral take part in an weekend and on- call rota whichis currently a 1 in 3.5 rota frequency, enabling 24 hour access to SPC advice as recommended byNICE and 9-5, seven day access to face- to- face contact with Clinical Nurse Specialists.Service developmentKey themes emerging from our service gap analysis are: As highlighted in the most recent Care Quality Commission inspection report, the level ofconsultant resource needs to be increased in order to ensure effective leadership of thespecialist integrated service and implementation of this strategy; to enable round-theclock access to specialist input, and also as a key means of developing the capabilities ofclinical leaders from other areas. Deficits in senior nurse manager input for the hospital andadministrative support have also been identified. Processes can benefit from standardisation to support quality, efficiency, co-ordination andintegration, e.g. use of shared assessment and care frameworks, including the NW End ofLife Care Model, advance care plans, discharge documentation, a shared minimum datasetfor monitoring, and a single approach for capturing and reviewing service activity The current service can benefit from greater integration e.g. a removing duplicate systems fordocumenting care, a shared programme of learning and development, more collaborativeworking with other specialist teams, integrated risk reporting and management Unmet training and education needs should be addressed, e.g. recognition of life-limitingillness and opportunities to begin open conversations about the needs and preferences ofthe dying person and those close to them including advance planning; communication andskills training for staff at every level to deliver effective, individualised and holistic care,including after death and bereavement support4. Strategic aims and objectivesThese are the steps we plan to take in order to achieve our vision of excellence in palliative andend of life care.I. Delivering system-wide improvements that make the best use of quality frameworks andspecialist expertisei. Conduct workforce review to build capacity and clinical leadership Develop a business case to bring consultant resource up to the level recommendedin national guidelines and create a senior nurse manager role at WUTH to ensureeffective management of the Integrated Specialist Palliative Care Team ( ISPCT) Secure appropriate levels of administrative support for consultants and the ISPCTteam Enable service leaders, managers and team-members to regularly review in-hospitalactivity enter in order to evaluate CNS staffing sufficiency against the clinical andservice developmental demands of this roleii. Configure palliative and end of life care around recognised quality frameworks Fully embed high impact enablers – NICE Quality Standards, advance care planning,
EPaCCS, the Amber Care bundle and revised rapid discharge to die SOP Launch the Wirral multidisciplinary Record care for adults in the last days of life,incorporating the five priorities from One Chance to Get it Right. Support with Cernersolutions e.g. anticipatory prescribing order set; develop tracking system to deliver‘real time’ quality assurance and targeted support in the last days of life Adopt and use the North West End of Life Care model to raise the profile of specialistpalliative care as well as care at the end of lifeiii. Develop clinical governance structures underpinned by a culture of ‘information foraction’ Continue to participate in national and local audit and action-planning, e.g. theNational Care of the Dying in Acute Hospital auditxv , the CODE survey of bereavementexperiencexvi, death certification audit and introduce the WUTH bereavement serviceaudit. Develop Cerner IT solutions to streamline audit activity. Ensure all WUTH and Wirral Community Trust incidents, formal complaints andinformal feedback are reviewed and acted upon, the risk register is updated andlearning is shared Wirral Palliative and End of Life Care Team meetings will also provide oversight andinput into monitoring and review of specified policies with relevance to end of lifeand palliative care Continue to develop and implement the palliative and end of life care dashboardand feed information into formal healthcare needs assessment in order to evaluateand further develop the service Use Advancing Quality and Listening into Action methodologies to drive servicecontinuous improvementsII. Investing in and empowering staff to approach care towards the end of life as ‘everybody’sbusiness’i. Develop a communications plan to support the launch of the new three year strategyand re-launch the serviceii. Grow the knowledge, skills and capabilities of all End of Life and Palliative care teammembers Agree a shared programme of training and development across WUTH, communityand hospice settings, including formal education and more informal, staff-ledlearning opportunities Enhance skills in quality improvement, change management and teaching Develop individual special interest areas to enrich the team’s professional expertise,raise the profile of the service particularly in non-cancer specialties and strengthenongoing involvement in quality improvement workiii. Understand and meet the training needs of clinical and non-clinical WUTH staff andvolunteers Conduct a comprehensive training assets and needs assessment Develop a training and development offer for staff at all levels, which is values-basedand emphasises effective caring and communication skills. Further develop link nurserole on wards
Clinical skills sessions should include, training on the use of new tools and processes,e.g. advance care planning, the record of care for patients in the last days oflife; knowledge and skills development, e.g. individualised holistic assessment,anticipatory prescribing and symptoms management; organ donation; expectationsand responsibilities e.g. for involvement of important others, documentation anddeath certification; and the support available from ISPCT Where appropriate regular end of life and palliative care training should be linkedto frameworks such as appraisal, revalidation and personal development planning Explore hospice and community/ward staff exchange and insight programmes toimprove cross-organisational knowledge, skills and collaborative workingIII. Co-ordinating and planning care more effectively by working more collaboratively andprioritising integrationi. Standardise documentation and IT systems Wherever possible, agree and adopt shared assessments, care plans, resources e.g.symptom control formulary, discharge summaries, clinical recording systems andactivity capture across settings Proactively engage with opportunities presented by Healthy Wirral and the HealthInformation Exchangeii. Devote time to team-building Be able to articulate an open and shared sense of purpose and vision for the ISPCTand end of life team functions within WUTH Trial new approaches to routine service delivery and learn from models elsewhereiii. Develop the multi-disciplinary team base for specialist and complex care Use 6-12 month secondments to secure dedicated specialist input into the ISPCT fromallied health professionals, e.g. a physiotherapist, occupational therapist, dietitian,psychologist, pharmacist, discharge co-ordinator, and social workeriv. Develop more integrated relationships with other specialties Support the Trust’s work on readmissions and length of stay by collaboratingmore closely with teams such as gastroenterology, renal, cardiology, respiratory,haematology, emergency medicine and community geriatricians Improve communication and collaboration with allied teams such as risk management,the bereavement service, integrated discharge team and the critical outreach team.Re-establish partnership working with CNSs from other specialties.v. Adopt a system-wide perspective to service improvement Collaborate with Wirral Hospice and Wirral Community Trust to identify assets andopportunities to improve patient care and service efficiency Link outcomes to record of care and other electronic care-planning data to drive andmonitor system-wide improvements e.g. multi-agency review and action-planningaround preferred place of death outcomesvi. Interface with the wider community Champion the Wirral End of Life Charter and national campaigns such as DyingMatters
Although very few people die in circumstances where organ donation is possible thepatients’ views on organ donation will be sought where appropriate, ensuring theirwishes are facilitated.5. Framework for measuring progressThe objectives of this strategy will be the focus of service development and improvement overthe next three years. Key measurable outcomes include Experience of care will improve, including avoidance of unnecessary interventions as deathapproaches and positive feedback from surveys of the bereaved Services and care will be more co-ordinated and efficient, ensuring that conversationsabout palliative and end of life care involve the right people and happen at the right time. The skills and confidence of generalist and specialist staff will improve, supported by anadequate specialist staff base More people will die in the place they choose and many unnecessary admissions to hospitalwill be avoidedPatient flow will improve, demonstrated by reduced re-admission frequency and length of stayProgress on the implementation of key changes will be monitored within the action plan andreview process using a mixture of hard and soft indicators, such as updates at the monthlyWUTH End of Life Team meeting, audit, the End of Life care dashboard, incident reporting andqualitative feedback from people who receive care from the service.
iDH (2008) National End of Life Care strategy -careiiOffice of National Statistics Deaths registered in England and Wales in 2014 y/birthsdeathsandmarriages/deathsiiiDr Foster http://www.drfoster.com/ivPublic Health England (2014). The Older People’s Health and Wellbeing Atlas http://www.wmpho.org.uk/olderpeopleatlas/vGomes et al (2011) Local preferences and place of death in regions within England 2010 rces/publications/lp and place of deathviPublic Health England (2013) National End of life Care Intelligence Network. End of Life Care Profiles http://www.endoflifecare-intelligence.org.uk/end of life care profiles/viiPollock K (2015) Is home always the best and preferred place of death? BMJ 2015;351:h4855viiiClark M et al (2014) Imminence of death among hospital inpatients: prevalent cohort study Palliative MedicineDOI 10.1177/0269216314526443ixNHS England (2015)Transforming end of life care in acute hospitals - The route to success ‘how to’ guide(revised December 2015) d-of-life-care/xNHS England (2014) Actions for End of Life Care: 2014-16xiNational Palliative and End of Life Care Partnership (2015) Ambitions for Palliative and End of Life Care: Anational framework for local action 2015-2020 http://endoflifecareambitions.org.uk/xiiLeadership Alliance for the Care of Dying People (2014) One chance to get it right -Improving people’sexperience of care in the last few days and hours of life iiNICE (2011) End of life care for adults quality standards http://www.nice.org.uk/Guidance/QS13xivNICE (2015) Care of dying adults in the last days of life http://www.nice.org.uk/guidance/ng31xvRCP (2015) nal-care-dying-audit-hospitalsxviMayland CR, Lees C, Germain A et al. Caring for those who die at home – the use and validation of‘Care Of the Dying Evaluation’ (CODE) with bereaved relatives. BMJ Support Palliat Care doi: 10.1136/bmjspcare-2013-000596
The 2016-19 Palliative and End of Life Care Strategyis also available online.Visit www.wuth.nhs.ukand search ‘End of Life Care’.For more information contactthe End of Life Care Team on extension 8437#PROUD TO CARE FOR YOUwuth.nhs.uk@wuthnhs
Adult Palliative and End of Life Care Strategy 2016-19 Vision: Our ambition is to make palliative and end of life care as good as it can possibly be each and every time. By working together we will provide care that is well planned, compassionate, holistic, and focused on continuously meeting the needs of the individual and those close to them Objective No.1
DEPARTMENT DIVISION NAME Family Medicine Palliative Medicine Algu,Kavita Palliative Medicine Arvanitis,Jennifer Palliative Medicine Berman,Hershl (Hal) Palliative Medicine Buchman,Stephen (Sandy) Palliative Medicine Cellarius,Victor Palliative Medicine Goldman,Russell Palliative Medicine Hashemi,Narges Palliative Medicine Howe,Marnie
palliative care plan 2012-2016 Inpatient palliative care There are 300 specialist palliative care beds located in NSW public hospitals, affiliated hospitals and other facilities in the NSW health system. Care is also routinely provided in non-designated palliative care beds. In 2008-09, there were 19,800 palliative care
1 Palliative Care Quality End of Life Care Resource Book Palliative Care Needs Round Checklist (Based on the ACU and Calvary Palliative Care Needs Rounds Checklist) Palliative Care Needs Round Checklist Triggers to discuss resident at needs rounds One or more of: 1. You would not be surprised if the resident died in the next six months 2.
End of Life Nursing Education Consortium, Pediatric Palliative Care – ELNEC PPC ELNEC- Pediatric Palliative Care was designed and developed by 20 pediatric palliative care experts and piloted in 2003. Each year, at least three national train -the-trainer pediatric palliative care
Section 3 - Developing Quality Palliative and End of Life Care 1. Open discussion about palliative and end of life care should be promoted and encouraged through media, education and awareness programmes aimed at the public and the health and social care sector. 2. The core principles of palliative and end of life care should be a generic
4.4 Key findings on the current state of palliative and end of life care provision 37 4.4.1 Unmet needs and disparities in access to palliative and end of life care 38 4.4.2 Unmet needs and disparities when in receipt of palliative and end of life care 39 4.5 Ways forward: Recommendations for policy, practice and research
Regional Palliative and End-of-Life Care Coordinator. Senior CommUnity Care, Western CO. thosmith@voa.org Tom is passionate about educating others on palliative and end-of-life care. He is the co-chair of the National PACE Association's Palliative and End -of-Life Workgroup As an employee of Volunteers of America, he works with
The Strategy Unit Palliative & End of Life Care in the West Midlands, 2017 i S:\Commissioning Intelligence And Strategy\Strategic Analytics\Projects 2016\NHSE WM EoLC\report\final update\Palliative and End of Life Care in the West Midlands - final - 171005.docx Document Title Palliative and End of Life Care in the West Midlands Job No SU331
