Decisions At Lifes End

1
Decisions At Lifes End
Rutland County Council

• Partnerships for Older People Project
• Leicestershire Rutland County Councils and
• Leicestershire County Rutland Primary Care Trust

2
DALE

• Aim
• To reduce the increasing number of older
• people who die in hospital
• By
• Providing the infrastructure in primary and
  community
• care that enables older people the choice of
  being
• cared for in their own home or closer to
• home in the last 72 hours of life

3
DALE

• Background
• 1489 LCRPCT Patients died in UHL
• during 2005-06 (who had no invasive
  intervention
• that could only have been carried out in
  hospital)
• 1869 scaled up estimated deaths in hospital
  
• 93 - 60 years and
  over
• 69 - Length of stay 14 days or less
• 50 - Length of stay 7 days or less

4
DALE

• Phased Roll Out over 2 years
• Started May 2007
• Nursing / Care Homes Current
• Sheltered Housing - October 2007
• Own home with Carer Support
• Own home alone

5
DALE

• Capacity increased by
• 11 new staff nurses
• 22 support workers recruited to Marie Curie
• 10 Befriender volunteers (Age Concern)
• Handy Person Service
• Quick Access Equipment Service

6
DALE

• Not a new service a Pathway
• Aims To Integrate Existing Services
• District Nurses
• Community Nursing Teams
• Marie Curie
• Out Of Hours Nursing Teams
• Community Matrons

7
DALE

• The service will be led and coordinated by
  Community Nursing Teams
• Referrals direct to the Community Nursing Team
• Referrals may come from
• District Nurses
• Hospice at Home
• Marie Curie
• Macmillan Nurses
• Specialist Nurses
• Care Home Staff

8
DALE

• Continued

• GPs
• Out Of Hours Nursing Teams Teams
• Community Matrons
• UHL Discharge Teams
• UHL Ward Nurses
• Community Hospitals
• Loros

9
DALE

• THE DALE PATHWAY COMMUNIITY REFFERAL
• Deterioration in condition 
• Contact made for medical assessment
• GP Visit (or On Call nurse)
• Patient considered to be dying.
• Has patient expressed a wish to
• Die at home
• Care needs can be met at home
• Request for DALE service
• (GP calls direct to DN or Out Of Hours DN
  Service)
• Assessment
• All care and support provided in line with
  personalised care plan.

10
DALE

• THE DALE PATHWAY ACUTE OR COMMUNITY HOSPITAL
• Terminally Ill Patient Requests To Be Enabled To
  Die At Home
• Or
• Patient Is Admitted to AE or Admissions And
  Palliative Care Is Recommended
• Acute Hospital calls direct to Community Nursing
  Team or Out Of Hours Service
• Telephone Assessment Of Patients Needs
• Patient Discharged Home
• All care and support provided in line with
  personalised care plan.
• DALE service intervention for 48 72 hours
• Continual review of support needed
• Patient dies.

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The Framework For Care Home Residents Care And
End Of Life Wishes
DALE
Resident Admitted To Care Home
Step 1. Resident assessed by Manager,Key
Worker,Dale Nurse or District Nurse And is
registered on the Gold Standard Register End of
life wishes discussed,assessed and
recorded. Residents condition monitored
Step 2. Resident Appears to have entered the last
3 to 5 days of life manager or care staff to
inform Community Nursing Team or DALE
Nurse Resident enters DALE pathway
Step 3. Residents End Of Life Care delivered
using Liverpool Care Pathway tool As part of the
DALE service
Resident Dies Their Wishes Having Been Followed
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The Framework For Older People In The Community
and End Of Life Wishes
DALE
Step 1. Older people speak to their GP about
their end of life wishes End of life wishes
discussed,assessed and recorded. And registered
on the GP Practice Gold Standard Register
Step 2. Older Person Appears to have entered the
last 3 to 5 days of life GP informs Community
Nursing Team or DALE Nurse Resident enters DALE
pathway
Step 3. Residents End Of Life Care delivered
using Liverpool Care Pathway tool As part of the
DALE service
Resident Dies Their Wishes Having Been Followed
13
DALE
Challenges
  Care Home Engagement   Use Of Gold Standard
Frame Work Use Of Liverpool Care Pathway Lack
of confidence in Palliative Care Difficulties
Out of Hours deputising GP does not know the
residents
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Challenges
DALE
Community Nursing Teams Could be perceived as
extra work Confidence relating to the
assessment process Out Of Hours Provision Not
Consistent Around The County  
15
DALE
Challenges

• General Practitioners Engagement
•  
• Gold Standard Framework often Cancer Led
• Concerns around litigation
• Deputising services lack confidence to enable
  patients to remain at home to die
• Engaging In Conversation Around End Of Life
  Issues
•  Communicating Patients End Of Life Wishes
  Effectively

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Challenges
DALE
Public
Effective Communication Confidence in service
delivery and quality of care Older people
perceiving that they do not have a choice to
receive active treatment in hospital Vulnerable
older people may not be aware of the service
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EVALUATION OF THE LEICESTERSHIRE AND RUTLAND
DECISIONS AT LIFES END (DALE) SERVICE

Kay Phelps Leicester Nuffield Research
Unit University of Leicester
18
EVALUATION OF THE LEICESTERSHIRE AND RUTLAND
DECISIONS AT LIFES END (DALE) SERVICE

Kay Phelps Leicester Nuffield Research
Unit University of Leicester
19
DALE Evaluation
Aim To undertake a formative evaluation over
the two year pilot period of the DALE service

• Objectives
• To investigate the opinions and practices of
  health and social care workers
• To investigate the attitudes, needs and wishes of
  older people and carers in regard to end of life
  care
• To measure hospital bed days saved and numbers
  helped to die at home
• To look at individual cases and assess the
  strengths and weaknesses of service provided
• To facilitate the National POPP evaluation

20
EVALUATION OF THE LEICESTERSHIRE AND RUTLAND
DECISIONS AT LIFES END (DALE) SERVICE

Kay Phelps Leicester Nuffield Research
Unit University of Leicester
21
DALE Evaluation
Aim To undertake a formative evaluation over
the two year pilot period of the DALE service

• Objectives
• To investigate the opinions and practices of
  health and social care workers
• To investigate the attitudes, needs and wishes of
  older people and carers in regard to end of life
  care
• To measure hospital bed days saved and numbers
  helped to die at home
• To look at individual cases and assess the
  strengths and weaknesses of service provided
• To facilitate the National POPP evaluation

22
DALE Evaluation

Methods

• Focus groups with health and social care staff
• Focus groups with older people and carers
• Identification collection and analysis of data on
  deaths at hospital / home
• Case study work involving interviews with staff
  and relatives
• Assisting with collection of data for National
  Evaluation team